LIBRARY OF CONGRESS, 

Chap. ... AY:' Copyright No. 

Shelf„_Ll_k 

im . 



UNITED STATES OF AMERICA. 



LESSONS 



IN 



PHYSICAL DIAGNOSIS 



ALFRED L. LOOMIS, M.D., LL.D. 

PROFESSOR OF THE PRACTICE OF MEDICINE AND PATHOLOGY IN THE UNIVERSITY OF 
THE CITY OF NEW YORK 



KEVISED BY 

ALEXANDER LAMBERT, M.D. 

VISITING PHYSICIAN TO BELLEVUE HOSPITAL; PROFESSOR OF CLINICAL MEDICINE 

AND INSTRUCTOR IN PHYSICAL DIAGNOSIS IN CORNELL UNIVERSITY; 

ASSISTANT BACTERIOLOGIST, HEALTH DEPARTMENT, 

NEW YORK 



ELEVENTH EDITION— REVISED AND ENLARGED 



NEW YORK 

WILLIAM WOOD AND COMPANY 

MDCCCXCIX 








.V 



«\°v 



. 






m 



44306 



Entered according to Act of Congress, in the year 1899, by 

WILLIAM WOOD & COMPANY, 
in the Office of the Librarian of Congress, at Washington. 



ALL RIGHTS RESERVED. 



TWO COPIES RECEIVED. 




•ECOND COPY, 






PEEFATOEY NOTE. 



The eleventh edition of this volume has been thor- 
oughly revised, and such corrections and additions have 
been made as seemed necessary to make it a more com- 
plete guide to the student of Physical Diagnosis. The 
lessons on the Examination of Urine and Clinical 
Microscopy have been entirely rewritten. A new sec- 
tion on the Examination of Stomach Contents has 
been added. 

The Eeviser has endeavored to leave untouched, as 
far as possible, the lessons on Physical Diagnosis, de- 
siring that they should remain as their distinguished 
author wrote them. 

Alexander Lambert. 

125 East Thirty-sixth Street, 
September, 1899. 



VI CONTENTS. 

LESSON X. 

PAGE 

Methods of Cardiac Physical Examination 89 

LESSON XI. 

Abnormal Sounds of the Heart 97 

LESSON XII. 

Synopsis of the Physical Signs of Pericarditis — Hypertrophy, 
Dilatation, and Fatty Degeneration of Heart, and Aneu- 
risms of Thoracic Aorta , . . . . 113 

LESSON XIII. 

Aneurism of the Thoracic Aorta and Arteria Innominata — 
Epigastric Pulsation— Subclavian Murmurs— Venous Pul- 
sations and Murmurs 121 

LESSON XIV. 

Abdomen— Introduction— Topography of the Abdomen— Con- 
tents of the Various Regions— Abdominal Inspection, Pal 
pation, Percussion, and Auscultation— Diseased Conditions 
of the Peritoneum 131 

LESSON XV. 

Physical Signs of the Abnormal Changes in the Different 
Abdominal Organs — Stomach— Intestines — Liver — Spleen . 141 

LESSON XVI. 

Physical Signs of the Abnormal Changes in the Different 
Abdominal Organs— Continued. 158 

LESSON XVII. 

Urine— Introduction — Plan of Examination — Physical Charac- 
ters— Chemical Characters— (a) Normal Elements, (b) Ab- 
normal Elements, 175 

LESSON XVIII. 

Clinical Microscopy — Blood, Sputum, Urine, Vomit, Faeces. . . 211 



CONTENTS. Vll 

LESSON XIX. 

PAGE 

Mechanical Aids in the Diagnosis of the Diseases of the Respir- 
atory and Vascular Organs — Stethoscope — Stethometek 
— Cyrtometer — Cardiometer — Laryngoscope — Sphygmo- 
graph 299 

LESSON XX. 

Mechanical Aids in the Diagnosis ok Diseases of the Nervous 
System, and in General Diseases— Ophthalmoscope — Ther- 
mometer — Microscope — Dynamometer — ^Esteesiometer— 
Exploring Trocar— Specula 315 



LIST OF ILLUSTRATIONS. 



FIG. PAGE 

1. The anterior region of chest, the boundaries of its subdivisions, 

and the organs corresponding to these subdivisions, . . 5 

2. The posterior region of chest, the boundaries of its subdivi- 

sions, and the organs corresponding to these subdivisions, 8 

3. Diagram illustrating the production of rales, .... 41 

4. Cavernous respiration and gurgles, 44 

5. Roughening of the pleurae, and slight pleuritic effusion, . 45 

6. Diagram illustrative of the physical signs of the three stages of 

pneumonia, 58 

7. Diagram showing the pleural cavity completely filled with 

liquid, the lung being compressed, ..... 68 

S. Diagram illustrative of the physical signs of hydro-pneumo- 

thorax, 73 

9. Diagram showing the changes in the valves and cavities of one 

side of the heart during a cardiac pulsation, ... 84 

10. Representation of the movements and sounds of the heart dur- 

ing a cardiac cycle, 86 

11. Representation of the altered relations of the sounds in slowed 

or accelerated heart action, 87 

12. Diagram illustrating the mode of production of cardiac mur- 

murs in the left heart, and the condition of the valves and 
cavities during their production, 100 

13. Diagram showing the areas of cardiac murmurs, . . . 104 

14. Diagram showing the pericardial sac partially filled with liquid, 

and plastic exudation upon the two surfaces of the pericar- 
dium above the level of the liquid, 114 

15. Hypertrophy of left ventricle, 116 

16. Hypertrophy of right ventricle, 117 

17. Diagram showing the different regions of the abdomen, and 

the organs contained in each, which are visible on the re- 
moval of the abdominal walls, . . . . . . 133 

18. The volume of the liver in various diseases, . 146 

19. Diagram representing the different areas occupied by the 

spleen in its various enlargements into the abdominal cavity. 155 

20. Diagram showing the gradual enlargement of a tumor of the 

right ovary till it fills a large portion of the abdominal cav- 
ity, 16' : 



LIST OF ILLUSTRATIONS. 



FIG. 




PAGE 


21. 


Urinometer 


180 


22. 


Ureometer, ........ 


182 


23. 


Improved ureometer, ...... 


183 


24. 


Albuminometer, . . . . . . _ . 


199 


25. 


Saccharometer, ....... 


205 


26. 


Cellular elements of human blood, 


212 


27. 


Thoma-Zeiss pipettes 


215 


28 and 29. Thoma-Zeiss counting slide, 


217 


30. 


Field of thirty -six squares in ruled disc, of Thoma 


-Zeiss 




counter, 


218 


31. 


Modified ruling of Thoma-Zeiss counting chamber, 


220 


32. 


Blood from case of leucocythaemia, 


223 


33. 


Poikilo-, macro-, and microcytes, . . ' . 


226 


34. 


Fleischl's haemometer, ...... 


227 


35. 


Normal blood, ....... 


230 


36. 


Blood in pernicious anaemia, .... 


230 


37. 


Blood in chlorosis, 


231 


38. 


Blood in chronic secondary anaemia due to bleeding pile 


is, . 231 


39. 


Pure culture of typhoid bacilli, .... 


234 


40. 


Typhoid bacilli — partial reaction, 


234 


41. 


Typhoid bacilli — typical clumping, 


234 


42. 


Spirillum of relapsing fever, .... 




43. 


Bacillus of anthrax, . ..... 


240 


44. 


Bacillus of typhoid fever, . . 


240 


45. 


Parasite of tertian malaria, 


242 


46. 


Parasite of quartan malaria, 


243 


47. 


Parasite of aestivo-autumnal malaria, 


244 


48. 


Flagellate malarial organisms, .... 


246 


49. 


iEstivo-autumnal parasites, crescentic forms, 


247 


50. 


Filaria sanguinis hominis, ..... 


247 


51. 


Curschmann's spirals, 


252 


52. 


Bronchial cast, ....... 


252 


53. 


Elastic tissue, . 


252 


54. 


Tubercle bacilli from sputum, .... 


256 


55. 


Actinomyces, or ray fungus, .... 


258 


56. 


Pneumococcus, .... ... 


258 


57. 


Echinococcus booklets, ..... 


259 


58. 


Urate of soda, 




59. 


Urate of soda with spicula 


263 


60. 


Urate of ammonia, ...... 


263 


61. 


Uric acid, 


265 


62. 


Calcium oxalate . 




63 and 64. Ammonio-magnesium, or "triple" phosphates, 


266 


65. 


Calcium phosphate, ....... 


267 


66. 


Cystin, 


267 


67 


Leucin 


268 


68. 


Tyrosin, ......... 


268 



LIST OF ILLUSTRATIONS. 



XI 



FIG. 

69. Pus corpuscles, . 

70. Pus corpuscles treated with acetic acid 

71. Epithelial cells 

72. Spermatozoa, . 

73. Types of hyaline casts, 

74. Epithelial casts 

75. Granular casts, 

76. Fatty casts 

77. Blood casts 

78. Torula cerevisia?, ... 

79. Penicilium glaucum, .... 

80. Sarcinae, 

81. Gonococci, 

82. Haernin crystals, 

83. Spirillum cholera? Asiatics, 

84. Amoebae coli, 

85. Distoma hepaticum, .... 

86. Head of taenia solium, .... 

87. Head and proglottides of taenia mediocanellata 

88. Egg of bothriocephalus latus, 

89. Head and anterior end of strobile of bothriocephal 

90. Oxyuris vermicularis, . 

91. Eggs of nematode worm, 

92. Ascaris lumbricoides. 

93. Stethoscope, 

94. Phonendoscope, . 

95. Stethometer, 

96. Cyrtometer, . 

97. Cardiometer, 

98. Laryngeal mirror, 

99. Head mirror, 

100. Nasal speculum, . 

101. Marey's sphygmograph, 

102. Normal pulse tracing, .... 

103. A dicrotic pulse tracing, 

104. Pulse tracing in aortic regurgitation, . 

105. Pulse tracing in aortic stenosis, . 

106. Pulse tracing from a case of atheroma, 

107. Tracing from frequent pulse, 

108. Pulse tracing in mitral obstruction, 

109. Pulse tracing in aneurism of ascending aort 

110. Liebreich's ophthalmoscope, 

111. Straight self -registering thermometer, . 

112. Microscope, 

113. Dynamometer, ..... 

114. iEthesiometer 

115. Dieulafoy's exhausting syringe, . 



us latus 



269 
269 
270 
271 
272 
273 
273 
273 
273 
274 
274 
274 
275 
277 
289 
290 
291 
292 
292 
293 
293 
294 
294 
295 
300 
300 
301 
302 
304 
304 
305 
308 
310 
312 
312 
313 
313 
313 
314 
314 
314 
316 
32-2 
327 
328 
329 

331 



LUNGS. 



LESSOR I. 

INTRODUCTION — TOPOGRAPHY OF THE WALLS OF THE 
CHEST — CONTENTS OF THE VARIOUS REGIONS. 

Gentlemen . 

Physical Diagnosis is a term used to designate those 
methods which are employed for detecting disease dur- 
ing lif e by the anatomical changes which it has produced. 
The nature and extent of such changes can be recognized 
and appreciated by the deviations which they cause in 
the affected organs from the known physical condition 
of these organs when in health. The significance of 
physical signs in disease can be determined, not by the- 
ory, but only through clinical observation confirmed by 
examinations after death. 

There are five methods of eliciting these physical signs, 
termed " physical methods of diagnosis," viz., Inspec- 
tion, Palpation, Mensuration, Percussion, and Ausculta- 
tion. 

The most important of these are Auscultation and Per- 
cussion. The other methods are only subsidiary to these 
two, and can seldom be regarded as furnishing positive 
evidence of disease. For a complete and accurate physi- 
cal exploration you must sometimes employ all these 
different methods, and with all, therefore, you should 
become familiar. 

In order to localize physical signs, the chest has been 
divided into artificial regions ; but as the limits of these 



4 PHYSICAL DIAGNOSIS. 

regions are arbitrary, the boundaries adopted by different 
writers vary. The following divisions, which correspond 
very nearly to those proposed by many authorities, 
you will find, I think, sufficiently small and well de- 
fined for practical purposes. It is important that you 
should be f amiliar, not only with the boundaries of these 
regions, but with the relative position of the structures 
and organs or portions of organs included within them. 

The surface of the chest may be divided into three 
general regions — Anterior, Posterior, and Lateral. The 
Anterior region, on either side, may be subdivided into 
Supra- Clavicular, Clavicular, Infra- Clavicular, Mam- 
mary, and Infra-Mammary. Between the two anterior 
regions we have the Supra- Sternal, Superior Sternal, 
and the Inferior Sternal. The Posterior region, on 
either side, may be subdivided into the Supra- Scapular, 
Scapular, and Infra- Scapular. Between these you 
have the Inter -Scapular. The Lateral region, on either 
side, may be subdivided into Axillary and Infra-Axil- 
lary regions. 

The Supra- Clavicular region is a triangle whose 
base corresponds to the trachea ; whose lower side, to the 
upper border of the clavicle ; and whose upper side, to a 
fine drawn from the outer third of the clavicle to the 
upper rings of the trachea. This region contains, on 
either side, the apex of the lung, with portions of the 
subclavian and carotid arteries, and the subclavian and 
jugular veins. 

The Clavicular space is that which lies behind the 
inner three-fifths of the clavicle, and has the bone for its 
boundary. It is occupied on both sides by lung tissue; 
on the right side, at its outer extremity, lies the subcla- 
vian artery ; at the sterno-clavicular articulation, the 
arteria innominata. On the left side, almost at right 



INFRA-CLAVICULAR REGION. 5 

angles with the bone, and deeply seated, are the carotid 
and subclavian arteries. 

The Infra-Clavicular region has for its boundaries 
the clavicle above, the lower border of the third rib be- 
low, the edge of the sternum inside, and outside a line 
falling vertically from the junction of the middle and 




Fig. 1. — The Anterior Kegion, the Boundaries of its Subdivisions, and the Organs cor- 
responding to these Subdivisions. 



outer thirds of the clavicle. Within these limits, on 
both sides, you will find the superior lobe of the lung 
and the main bronchi; the right bronchus lies behind, 
and the left a little below the second costal cartilage. 
On the right side, close to the sternal border of the re- 
gion, lie the superior cava and a portion of the arch of 



6 PHYSICAL DIAGNOSIS. 

the aorta; on the left, a portion of the pulmonary artery. 
The aorta and pulmonary artery are immediately behind 
the second sterno-costal articulations; the one on the 
right, the other on the left side of the sternum. On the 
left side the lower boundary of the region very nearly 
corresponds to the base of the heart. 

The Mammary region is bounded above by the third 
rib ; below, by the inferior margin of the sixth rib ; in- 
side, by the edge of the sternum ; and outside, by a verti- 
cal hue, continuous with the outer border of the infra- 
clavicular region. You will find this region to differ 
materially in its contents on the two sides. On the 
right side the lung is found extending, in front, down to 
the sixth rib, where its thin, sharp border very nearly 
corresponds to the lower boundary of the region. The 
right wing of the diaphragm, though not attached higher 
than the seventh rib, is usually pushed up by the liver 
as high as the fourth interspace ; a portion of the right 
auricle of the heart, and the superior angle of the right 
ventricle, he close to the sternum, between the third and 
fifth ribs. On the left side the lung is in front as far as 
the fourth sterno-costal articulation, where its anterior 
border passes outward until it reaches the fifth rib 
(leaving an open space for the heart); then it crosses 
forward and downward as far as the sixth rib ; a small 
portion of the apex of the right ventricle is also found 
within this region. 

The Infra-Mammary region is bounded above by the 
lower border of the sixth rib; below, by a curved hue 
corresponding to the edges of the false ribs; inside, by 
the inferior portion of the sternum ; and outside, by the 
continuation of the outer boundary of the mammary re- 
gion. This region, on the right side, contains the liver, 
with a portion of the lung in front, on a full inspiration. 



LOWER STERNAL REGION. 7 

On the left, lying in front, near the median line, you 
have a portion of the left lobe of the liver and the stom- 
ach. The stomach usually rises to a level with the 
sixth rib. 

The Supra-Sternal region is the space which lies im- 
mediately above the notch of the sternum, and is 
bounded on either side by the sterno-mastoid muscle. 
It is occupied chiefly by the trachea, by the arteria inno- 
minata at its lower right angle, and by the arch of the 
aorta, which sometimes reaches to its lower border, 
where, on firm downward pressure with the end of the 
finger, you will often be able to feel it. 

The Upper Sternal region is the space bounded by 
that portion of the sternum which lies above the lower 
margin of the third rib. In this region the lungs lie in 
front, but do not completely close in the space. Imme- 
diately behind them are the ascending and transverse 
portions of the aorta, and the pulmonary artery from its 
origin to its bifurcation. The left vena innominata crosses 
the sternum a little below its upper border. Situated 
deeply, at the junction of the first and second bones of 
the sternum, is the trachea, dividing into its two bron- 
chi. The pulmonary valves are situated behind the left 
edge of the sternum, at its junction with the third costal 
cartilage. The aortic valves are about half an inch lower 
down, and midway between the median line and the 
left edge of the sternum. 

The Lower Sternal region corresponds to that por- 
tion of the sternum which lies below the lower margin 
of the third rib. Throughout the whole extent of this 
region, on the right side, the lung is in front; it also ex- 
tends down on the left side as far as the fourth sterno- 
costal articulation; below this lies the greater part of the 
right ventricle, and a small portion of the left. The 



PHYSICAL DIAGNOSIS. 




Fig. 2.— The Posterior Region, the Boundaries of its Subdivisions, and the Organs cor- 
responding to these Subdivisions. (After Sibson.) 



INTER- SCAPULAR REGION. 9 

mitral valve, deepest of all, is situated behind the third 
left intercostal space, about one inch from the sternum ; 
the tricuspid valve is near the middle of the sternum, 
at the level of the fourth costal cartilage. Inferiorly is 
the attachment of the heart to the diaphragm; below 
this is a small portion of the liver, and sometimes of the 
stomach. 

The Supra-Scapular and Scapular regions together 
occupy the space from the second to the seventh rib, and 
are identical in their outlines with the upper and lower 
f ossae of the scapula. These regions are occupied by 
lung substance. 

The Infra-Scapular region is bounded above by the 
inferior angle of the scapula and the seventh dorsal ver- 
tebra; below, by the twelfth rib; outside, by the poste- 
rior border of the lower axillary region ; and inside, by 
the spinous processes of the vertebrae. Immediately un- 
derneath the surface, as far as the eleventh rib, this re- 
gion is occupied by the lungs. On the right side the 
liver extends downward beyond the level of the eleventh 
rib ; on the left the intestine occupies the inner part of 
this region, and the spleen the outer. Close to the spine, 
on each side — more on the left than on the right — a 
small portion of the kidney is found; along the left side 
of the spine runs the descending aorta. 

The Inter-Scapular region is the space between the 
inner margin of the scapula and the spines of the dorsal 
vertebrae, from the second to the sixth. This region 
contains, on both sides, lung substance, the main bron- 
chi, and the bronchial glands. It also encloses on the 
left side the oesophagus, and from the upper part of the 
fourth dorsal vertebra downward, the descending aorta. 
The bifurcation of the trachea will be found opposite the 
third dorsal vertebra. 



10 PHYSICAL DIAGNOSIS. 

The Axillary region has for its limits the axilla, 
above ; below, a line carried backward from the lower 
boundary of the mammary region to the inferior angle 
of the scapula; in front, the outer margin of the infra- 
clavicular and mammary regions; and behind, the exter- 
nal edge of the scapula. This region corresponds to the 
upper lobes of the lungs, with the main bronchi deeply 
seated. 

The Infra- Axillary region is bounded above by the 
axillary region; anteriorly, by the infra-mammary ; pos- 
teriorly, by the infra- scapular; and below, by the edges 
of the false ribs. This region contains, on both sides, 
the lower edge of the lung sloping downward and back- 
ward, reaching in the mid-axillary lines to the ninth 
rib. On the right side from the ninth to the eleventh 
rib is the liver, on the left the spleen. The cardiac end 
of the stomach extends into this region on the left side. 



LESSOR II. 

INSPECTION, PALPATION, AND MENSURATION. 

Inspection is the ocular examination of the external 
surface. Though usually secondary in importance to 
Auscultation and Percussion, it should not be lightly re- 
garded, for it often furnishes you much information re- 
specting the condition of the thoracic and abdominal 
viscera. By Inspection you recognize changes in the 
size, form, or symmetry of the cavities in which they 
are contained, and in the movements of their walls dur- 
ing respiration, as regards their rhythm, frequency, or 
.force. 

As students of anatomy you are familiar with the 
form of a well-proportioned chest ; a description of it is, 
therefore, unnecessary. Suffice it to say that, in a nor- 
mal state, the two sides are symmetrical in every part ; 
the intercostal spaces are more or less distinct, accord- 
ing as the individual is more or less fat. Normal breath- 
ing is of two kinds, costal and diaphragmatic. In the 
costal the movements are chiefly thoracic ; in the dia- 
phragmatic they are chiefly abdominal. In quiet respi- 
ration you will notice the abdominal wall rise with in- 
spiration, and fall with expiration ; at the same time 
you will observe a lateral expansion of the lower ribs, 
and a slight upward movement of the upper part of the 
chest with inspiration, and a downward movement with 
expiration. The movements of respiration in these 
three situations are called, respectively, abdominal. 



12 PHYSICAL DIAGNOSIS. 

inferior costal, and superior costal. In the female, the 
costal breathing is most marked ; in the male, the dia- 
phragmatic. The number of respirations to the minute 
varies at different periods of life ; in childhood it is 
about twenty-six ; from the twentieth year, about six- 
teen to twenty. 

Considerable alterations in the form and movements 
of the chest are compatible with a healthy condition of 
the thoracic viscera. You rarely meet with a perfectly 
symmetrical chest, even among the healthy. In my ex- 
amination of fifteen hundred persons I found only one 
well-proportioned, symmetrical chest in seven. As you 
can easily recognize these healthy deviations from sym- 
metry, I shall not enter into details concerning them. I 
would, however, mention that slight curvatures of the 
spine, either acquired # or the result of former disease of 
the vertebras, cause the majority of these deviations. 

We will first consider only those changes in the size, 
form, and movements of the thoracic cavity which are 
the result of disease of the thoracic organs; confining 
ourselves, at present, to the lungs and pleurae. The 
readiest way of presenting these changes to you, it 
seems to me, is to consider them as they occur in the 
different thoracic affections. First we will consider the 
signs obtained by inspection in pleurisy. In the first 
stage, prior to the occurrence of much liquid effusion, 
there is no apparent change in the size, but the move- 
ments of the affected side are diminished, and those of 
the healthy are increased ; you have what is termed a 
catching respiration. This sign is not distinctive of 
pleurisy ; it is present in intercostal neuralgia and in 
pleurodynia. In the stage of liquid effusion, if the liquid 
is sufficient to compress the lung and dilate the thoracic 
walls, the affected side will be increased in size, and, in 



INSPECTION. 13 

proportion to the dilatation, its movements are restricted 
or arrested. If the cavity is completely filled with liquid, 
there will be bulging and widening of the intercostal 
spaces, with more or less displacement of the adjacent 
viscera. As the liquid is absorbed the lung expands, but 
not to the same volume it had before. It remains more 
or less contracted, and the consequence is, retraction of 
the affected side from atmospheric pressure. Generally, 
if the liquid effusion shall have existed a considerable 
length of time previous to absorption, the subsequent re- 
traction is marked, and you can determine at once by 
inspection that pleurisy has existed at some period more 
or less remote. 

In pulmonary emphysema, if it is a well-marked 
case, on inspection you will notice a dilatation of the 
upper portion of the chest, while t its whole aspect ap- 
pears more rounded than in health, so that it has re- 
ceived the name " barrel-shaped " chest ; the shoulders 
are elevated and brought forward ; the movements in 
respiration are limited to the lower portions of the chest 
and to the abdomen. On inspiration there is no out- 
ward expansive movement of the ribs ; the sternum 
and ribs seem to move up and down as if they were 
composed of one solid piece; in some cases of long stand- 
ing you will have actual falling-in instead of expansion 
of lower ribs during inspiration. In a well-marked 
case of emphysema, inspection is quite sufficient for a 
diagnosis ; but where the lungs are but slightly emphy- 
sematous, inspection furnishes no positive information. 
In pneumonia, the only sign furnished by inspection is 
that the movements of the affected side are restrained, as 
in the first stage of pleurisy. In pulmonary tuberculosis 
inspection furnishes you important information. De- 
pression in the infra-clavicular region on the affected 



14 PHYSICAL DIAGNOSIS. 

side is an early sign of tubercular deposit. In advanced 
tuberculosis, the depression is still more marked, in some 
instances amounting almost to deformity. The expan- 
sive movements in inspiration on the affected side, in 
the infra-clavicular region, are diminished or entirely 
wanting, and this want of expansion is often noticeable 
at a very early period in the disease. 

Bulging or partial enlargement of the chest, deter- 
minable by inspection, occurs in various affections. En- 
largement of the praeeordia is observed in certain cases 
of hypertrophy or dilatation of the heart, or from liquid 
effusion in the pericardium. Bulging occurs also over 
aneurismal and other tumors 

In cases of membranous croup, acute and chronic 
laryngitis, and oedema glottidis, inspection will disclose 
to you the seat of the obstruction to the passage of air 
to the lung by a sinking-in during inspiration of the 
parts of the chest which yield most readily to atmo- 
spheric pressure. This sinking-in on inspiration you 
will notice first in the supra-clavicular spaces, then in the 
infra-clavicular spaces, and, as the obstruction increases, 
the sternum is depressed and the sides contracted. 

Although furnishing few positive evidences of disease, 
you should always employ inspection prior to the other 
methods of physical exploration. This is important in 
all cases where the evidences furnished by the other 
physical signs are not conclusive. 

Palpation, or the act of laying on the hand and feel- 
ing the external surface of the body, is less useful than 
inspection in ascertaining deformities, and the amount 
of general movement ; but it is more useful in deter- 
mining the amount of local expansion, and the charac- 
ter of vibration or impulses communicated to the exter- 
nal surface. 



PALPATION. 15 

In order to arrive at satisfactory results from its em- 
ployment, you should observe the precautions already 
named as influencing accurate inspection ; beyond this, 
I need only mention that in thoracic examinations the 
hand or the fingers should be gently and evenly applied 
to the surface of the chest, and that corresponding por- 
tions of the two sides of the thorax should be examined 
simultaneously, the one with the right hand and the 
other with the left. If you lay your hand lightly upon 
the surface of the chest of a healthy person while speak- 
ing, a delicate tremulous vibration will be felt, varying 
in intensity with the loudness and coarseness of the 
voice and the lowness of its pitch ; this is called normal 
vocal fremitus. As a rule, vocal fremitus is more 
marked in adults than in children, in males than in fe- 
males, and in thin than in fat persons. In the right in- 
fra-clavicular region it is more marked than in the left. 
Variations in the vocal fremitus are the most important 
evidences of disease furnished by palpation ; in fact, all 
other evidences of pulmonary disease afforded by palpa- 
tion are better obtained by inspection. 

In disease, the normal vocal fremitus may be in- 
creased, diminished, or entirely absent. 

Increased vocal fremitus occurs in those affections in 
which lung tissue becomes more or less solidified, as 
in tuberculosis, pneumonia, pulmonary apoplexy, and 
oedema of the lung. When the consolidation is ex- 
treme, involving bronchial tubes of considerable size, 
the vocal fremitus may be diminished or even absent ; 
while increase in the size of the bronchial tubes, with 
the slight adjacent consolidation met with in chronic 
bronchitis, often gives rise to increased vocal fremitus. 

Diminution or absence of the normal vocal fremitus 
occurs whenever the lung substance is separated from 



16 PHYSICAL DIAGNOSIS. 

the chest walls by gaseous or liquid accumulations in 
the pleural cavity, as in pneumothorax, serous, plastic, 
hemorrhagic, or purulent pleuritic effusions, or when- 
ever the pleurae are thickened. In vesicular emphy- 
sema, owing to the dilated condition of the air cells, 
vocal fremitus is diminished. Besides these valuable 
indications furnished by vocal fremitus, you may em- 
ploy palpation to detect the friction caused in pleurisy 
by the rubbing together of the two roughened surfaces 
of the pleural membrane, and which is termed friction 
fremitus. 

Sibilant and sonorous rales also sometimes throw the 
bronchial tubes into vibration, sufficiently strong to be 
felt on the surface of the chest ; this is termed sonorous 
or rhonchial fremitus. Cavernous gurgles produced in 
excavations near the surface may be accompanied with 
a marked fremitus. 

Palpation may also be employed to detect points of 
tenderness, and to determine the density and condition 
of tumors. 

Mensuration is another method of physical explora- 
tion, employed for obtaining information similar to that 
furnished by inspection and palpation. We seldom em- 
ploy it in physical examinations of the lungs unless 
great accuracy is required, as in the record of cases. 
The instruments which have been devised for the mea- 
surement of the chest, and the different lines of measure- 
ment, are numerous. The circular measurement is the 
only one that I have found of practical value in investi- 
gating pulmonary disease. The simplest and most ac- 
curate mode of measuring the circular dimensions of the 
chest is by means of the instrument devised by Dr. 
Hare, which consists of two pieces of tape similarly grad- 
uated, joined together, and padded on their inner sur- 
face close to the line of junction ; the saddle thus 



MENSURATION. 17 

formed, when placed over the spine, readily adjusts it- 
self to the spinous processes, and becomes fixed suffi- 
ciently for the purpose of mensuration. For comparing 
the expansive movements of the two sides you will find 
Dr. Quain's stethometer ' very useful. The object of the 
circular measurement of the chest is twofold — first, to 
ascertain the comparative bulk of the two sides ;■ second, 
to ascertain the amount of expansion and retraction ac- 
companying inspiration and expiration of the two sides. 
The points of measurement are the spinous processes be- 
hind and the median line in front, on the level of the 
sixth costo-sternal articulation. 

The average circular dimension of the chest at this 
point in fifteen hundred healthy persons was thirty-two 
and a half inches. I also found in these examinations 
that about four-fifths of healthy adults have irregularity 
of the two sides. In right-handed individuals the right 
side is about one-half inch larger than the left ; in left- 
handed, the left. This is true of both sexes. 

The really important point of mensuration in pulmon- 
ary diseases is the comparison of the two sides of the 
chest, in rest and in motion. When a pleural cavity is 
distended with air or fluid, the measurement of the af- 
fected side may exceed that of the healthy side by two 
or three inches ; after the removal of the fluid there 
may be an equal diminution in the measurement of the 
affected side, as compared with the healthy one. 

Deficiency of expansion is also very marked in certain 
diseases. In empyema, for instance, you will often find 
the total difference between the fullest inspiration and 
the fullest expiration, on the affected side, will scarcely 
exceed one-sixteenth of an inch, while on the other side 
there may be a difference of two or three inches. 

1 See page 236. 



18 PHYSICAL DIAGNOSIS. 

The list of affections in which variations in expansion 
are to be estimated by measure are the same as those re- 
ferred to under the head of Inspection. 

The measurement of the capacity of the lungs for air, 
by means of Dr. Hutchinson's spirometer, or of the 
* ' vital capacity of the chest, " as he terms it, has been 
shown by experience to be very unreliable, and his in- 
strument has fallen almost entirely into disuse. 



LESSON III. 

PERCUSSION. 

Percussion, as a means of diagnosis, is not of recent 
date, for we find it mentioned by Hippocrates. But as 
the only mode of practising it was by striking the surface 
itself with the tips of the fingers, or knuckles, now 
termed, technically, immediate percussion, its uses were 
very limited. Within our time, however, M. Piorry gave 
it an entirely new value by introducing mediate percus- 
sion — the stroke being made, not on the surface, but on 
some intervening substance applied to it ; and he so 
demonstrated, by experiments on living and dead bodies, 
its superior applicability for determining changes in the 
subjacent parts, that mediate percussion ranks now only 
second to auscultation among the methods of physical 
exploration. 

To estimate the value of percussion and to understand 
its true significance, you must first learn to appreciate 
correctly the elements of sound. Authors have employed 
a variety of terms to designate them, such as clearness, 
dulness, emptiness, fulness, etc.; but I think that a 
classification based upon analysis of the elements of 
sound in general, will afford us the truest and most prac- 
tical distinctions, especially in estimating the sounds in 
thoracic percussion. Those elements or acoustic proper- 
ties of percussion sounds which concern us clinically are 
termed, respectively, Intensity, Pitch, Quality, and Du- 
ration. 



20 PHYSICAL DIAGNOSIS. 

The Intensity of a percussion sound may be increased 
or diminished by increasing or diminishing the force of 
the percussion blow. But in pulmonary percussion, you 
will find that the intensity depends not only on the force 
of the blow, but is further modified by the amount of air 
contained in the lung tissue, by the thickness of the soft 
parts covering the thoracic walls, and also by the elas- 
ticity of the costal cartilages. 

The Pitch of the percussion sound is always low over 
healthy lung substance, and, as a rule, the greater the 
quantity of air contained in the corresponding pulmonary 
tissue, the lower the pitch ; consequently, you will find 
the pitch of the percussion sound varying very percept- 
ibly in the different regions of a healthy chest. You 
can, however, familiarize the ear with the characters of 
normal pitch only by constant practice. 

Quality in sound is that element by which we distin- 
guish any given sound from every other. Thus it is by 
the quality that you know the sound of one musical in- 
strument from another. The quality of the note emitted 
on percussion over healthy lung substance, and termed 
normal vesicular resonance, is sufficiently marked and 
peculiar to be easily recognized, though it cannot be easily 
described, and is to be learned only by experience. 

The Duration of a given sound, you will find varying 
according to the pitch of that sound ; the higher the 
pitch, the shorter the duration, and vice versa. For ex- 
ample, the duration of the percussion sound is percept- 
ibly longer in the infra-clavicular region of a healthy 
chest than over the heart. 

You will find that a certain definable relationship ex- 
ists between these respective elements of the percussion 
note, which has a correspondence to the different regions 
of the chest. Thus, after noting the intensity, pitch. 



PERCUSSION. 21 

quality, and duration of the percussion sound in the 
infra-ciavicular region, you will find that over the heart 
it has a higher pitch and harder quality, but a less inten- 
sity and a shorter duration. 

The substance which receives the stroke in mediate 
percussion is termed a pleximeter, of which many varie- 
ties have been devised, made of wood, ivory, gutta 
percha, etc. They are in nowise superior, however, to 
the left index or middle fingers, when their palmar sur- 
face is applied evenly to the chest; for these, besides be- 
ing the most handy, also answer best the chief requisite 
of a pleximeter in that they can be easily fitted with 
accuracy to any part of the thoracic walls. Moreover, 
their own proper sound, on being struck, is inappreciable, 
which is not the case with ivory, wood, etc. Likewise, 
you will discover nothing better to strike with than the 
finger tips of the other hand, brought into line ; while, 
for gentle percussion, the middle finger alone may suf 
fice. 

Now, as the practice of percussion requires some 
manual dexterity, and the correctness of its indications 
depends in great measure upon the mode in which it is 
performed, you will find it useful to have recourse to 
the following rules as your guides : 

First. You should attend as carefully to the position 
of your patient as a photographer would, if he were 
going to take his likeness. Whether lying, sitting, or 
standing, his body should rest on the same plane, and 
his limbs be disposed similarly, on either side, so as tc 
render the muscular tissue covering the thoracic walls 
equally tense. In percussing particular regions, how- 
ever, the first aim is to make the intervening tissue as 
firm and thin as possible. Thus, when you percuss the 
front of his chest, the arms should hang loosely down. 



22 PHYSICAL DIAGNOSIS. 

but the head he thrown back. On the contrary, the 
arms should be raised to the level of the head when you 
are percussing the lateral regions, and should be crossed 
in front, the patient leaning moderately forward, w T hen 
you percuss the back. It is better to percuss on the 
naked skin, but various considerations may make this 
unadvisable. You should then aim to have the covering 
as soft, thin, and, especially, as even as possible. 

Second. The two sides of the chest should, for com- 
parison, be percussed at the same stages of the respira- 
tory act. You should, also, take care to compare only 
corresponding portions in the two sides. Thus, you 
should not compare a note during inspiration on the 
right side with one during expiration on the left, nor 
that over a rib with that of an interspace. 

Tliird. The finger, or pleximeter, should be applied 
with equal firmness, and in the same parallel, to both 
sides in succession, and the force of the percussion 
should be exactly the same ; for the sound will vary 
considerably even on the same spot, whether you press 
lightly or firmly with your finger, whetner it is across a 
rib or along it, and, finally, whether you strike gently or 
forcibly. 

Fourth. The stroke in percussion should be made 
from the wrist alone, the arm and forearm not partici- 
pating in it ; and its force should be proportioned to the 
depth of the part to be examined — gentle if superficial, 
and forcible when deep seated. 

Percussion in Health. — The significance of the per- 
cussion sounds in disease depends so entirely on their 
variation from the sounds which are proper to the part 
in health, that you cannot pay too much attention to 
the various characters of normal thoracic percussion; 
for on this almost every deduction which results from 



PERCUSSION. 23 

your examination is based. Now, the percussion sounds 
differ materially in a healthy thorax, according to the re- 
gion percussed. Taking the percussion note of the infra- 
clavicular region as the standard for pulmonary percus- 
sion, we find each of the other regions has its own 
variations from it. In the right infra-mammary region 
you will get, by gentle percussion, the same note as in 
the infra- clavicular ; but forcible percussion, at and be- 
low the f ourtn interspace, will raise the pitch and har- 
den the quality, owing to the presence of the liver be- 
hind the shelving border of the lung. Over the left 
infra-mammary region the pitch is similarly varied by 
the presence of the heart, until it reaches complete flat- 
ness at its inner border. The resonance of the right 
infra-mammary region has a harder quality, higher 
pitch, and shorter duration, from the presence of the 
liver immediately beneath. The left infra-mammary re- 
gion is similarly affected at its inner part by the left lobe 
of the liver, while the remaining space gives a tympan- 
itic resonance from the subjacent stomach. Over both 
clavicles you will get a mixed pulmonary and osseous 
resonance, while in the supra- sternal region the percus- 
sion sound has a distinctly tubular character. In the 
superior sternal region it has a bony tubular resonance 
down to the second rib; below this, to the third rib, it 
is raised in pitch and hardened in quality. The dulness 
on percussion becomes complete in the next region, or 
inferior sternal, owing to the presence of the heart and 
great vessels, together with the left lobe of the liver. 

The Superior and Middle Axillary regions are ex- 
tremely resonant as far down as the fourth interspace ; 
the pitch is even lower than in the infra-clavicular re- 
gion, but below the fourth interspace the pitch rises, till 



24 PHYSICAL DIAGNOSIS. 

complete dulness is found on a level with, and below, the 
seventh rib. This dulness continues through the infra- 
axillary regions on either side. 

In the Supra-Scapular and Scapular regions the 
percussion sound is high-pitched and hard in quality, 
except in the supra -spinous fossae, where it has the soft 
quality characteristic of pulmonary percussion. In the 
infra- scapular region you have pulmonary resonance as 
far down as the tenth rib, and complete flatness below. 
In the inter -scapular region the percussion is high- 
pitched and tubular in quality. 

Besides variations in percussion sounds dependent on 
difference in regions, there are still others ascribable to 
age, sex, idiosyncrasies, etc. You will find the percus- 
sion sound in children of a softer quality and lower 
pitch than in adults ; while in the aged it rises in pitch, 
and measurably loses its pulmonary quality. In females 
the percussion sound is relatively more pulmonary in all 
it's characters than in males. Marked deformity of the 
chest, whether congenital or acquired, also modifies the 
normal resonance. But it also varies materially in differ- 
ent individuals who are equally healthy. In some per- 
sons this difference may be accounted for, while in others 
it cannot ; but, as a rule, the thinner the chest walls, 
, the greater is the intensity, the lower the pitch, and the 
more pulmonary the quality of the percussion sound. 

Percussion in Disease. —It is obvious, from what 
precedes, that whatever modifies the density of the lung 
substance, and changes its proper elasticity, will cause 
a corresponding modification in the normal pulmonary 
resonance ; for as the lung texture is rendered more 
dense, or less so, than natural, the percussion sound 
passes through every gradation from marked resonance 
to complete dulness. These modifications, caused by dis- 



PERCUSSION. 'Zh 

ease, we would classify under the following heads, viz. : 
Exaggerated Pulmonary Resonance, Dulness, Flatness, 
Tympanitic Resonance, Vesiculo- Tympanitic Resonance, 
Amphoric Resonance, and Cracked-Pot Resonance. 

Exaggerated Pulmonary Kesonance consists in an 
increase of the intensity of the sound, the pitch being 
slightly lower, while the quality remains unchanged. 
This sign may exist to a slight degree over the whole or 
over a portion of a lung which is performing more than 
its usual share of labor. Thus, if one pleural cavity is 
filled with fluid, or if one lung is solidified by the exu- 
dation of pneumonia, or the seat of extensive tuberculous 
deposit, you will find the resonance of percussion in- 
creased on the opposite unaffected side, which is now 
doing double duty. Extensive anaemia, by lessening the 
quantity of blood in the lungs, may also give rise to 
slight extra resonance on percussion. 

Dulness. — This consists in a diminution of the pulmo- 
nary resonance, and may be slight, considerable, or 
complete, according as more or less air enters the af- 
fected part. In dulness the intensity is diminished, the 
pitch raised, the duration shortened, and the quality 
hardened. Dulness always indicates a decrease in the 
normal proportion of air in the part, and is an impor- 
tant physical sign in a number of diseases, as in pneu- 
monia, tuberculosis, oedema of the lungs, etc. 

Flatness. — This indicates the total absence of air, so 
that there is no proper pulmonary resonance, and its 
sound resembles that produced by percussing the thigh. 
We have examples of this when we percuss over liquid 
contained in the pleural or pericardial serous cavities, 
or when tumors are developed in the thorax, etc. 

Tympanitic Eesonance. — This is marked by the ab- 
sence of proper pulmonary quality in the characters of its 



2G PHYSICAL DIAGNOSIS. 

resonance, the type being the resonance of a tympanitic 
abdomen on percussion ; in intensity it exceeds normal 
pulmonary percussion, and is lower in pitch. 1 As a 
physical sign in thoracic affections it usually indicates 
the presence of air in the pleural cavity, as in pneumo- 
thorax. In this affection we have air contained, not in 
small vesicles, but in a large free space, and hence we have 
not the vesicular but the tympanitic quality in the sound. 

Vesiculotympanitic Resonance. — By this term (in- 
troduced by Prof. A. Flint) it is meant to denote a reso- 
nance in which we have both the tympanitic and vesicu- 
lar qualities. It is lower pitched but more intense than 
normal pulmonary resonance, and is present when the 
increase of the volume of the lung, as in some cases of 
emphysema, is so great as to dilate and render extremely 
tense the thoracic walls. 

Amphoric Resonance, unlike tympanitic resonance 
(which gives an impression of fulness), is suggestive of 
shallowness or emptiness ; it resembles the sound pro- 
duced by flapping the cheek when the mouth is closed, 
and fully but not forcibly inflated. It is most frequently 
heard over a large superficial cavity having thin, tense 
walls, and hence is usually indicative of phthisis. In 
cases of pleuro-pneumonia, a sound more or less amphoric 
in character is sometimes heard. 

Cracked-Pot Resonance is usually, though not in- 
variably, heard in connection with amphoric resonance. 
It resembles the sound produced by striking the hands, 
loosely folded across each other, against the knee, the 
contained air being suddenly forced out between the fin- 
gers. If there exists a pulmonary cavity of large size, 

1 Many authorities speak of the pitch as raised. I regard it lower 
than normal. But pitch is not an essential element. We recog- 
nize the tympanitic sound by its quality, not its pitch. 



PERCUSSION. 27 

with thin walls, communicating freely with a large 
bronchial tube, the chest walls being at the same time 
particularly yielding, forcible percussion, with the pa- 
tient's mouth open, will yield cracked-pot resonance. 
Dr. Hughes Bennett states that a cracked-pot reso- 
nance may be elicited in various diseases of the chest, and 
even when the chest is perfectly sound. I have never 
obtained true cracked-pot resonance unless over a pul- 
monic cavity or in pneumothorax. 

Auscultatory Percussion.— This is a combination of 
auscultation and percussion. It was first brought to 
the notice of the profession by Drs. Cammann and 
Clark in 1840. 

Their method of performing it was as follows : Press 
the objective end of a stethoscope, constructed expressly 
for this purpose J (while the ear piece is accurately fitted 
to the ear), firmly and evenly on the surface, directly 
over that portion of the organ or tumor to be examined 
which is most superficial ; then let percussion be per- 
formed in the usual way, one or two inches from the 
point at which the stethoscope is applied. The percus- 
sion sound communicated to the ear in this manner far 
exceeds in intensity and distinctness the same sound 

1 This instrument is a solid cylinder of wood, shaped in the direc- 
tion of the woody fibres, six inches in length and ten or twelve 
lines in diameter ; furnished with an ear piece which will allow 
nearly the whole cylinder to pass through it, so that it may apply 
directly to the tube of the ear, without change of medium. To 
avoid as much as possible the sound of the thoracic walls, as is de- 
sirable in some cases, this instrument has been modified by reduc- 
ing it at its objective extremity to a truncated wedge, leaving the 
other extremity as before. This is applied between the ribs so as 
not to touch them, and at the same time approach somewhat nearer 
the object under examination. — New York Journal of Medicine and 
Surgery, July, 1840. 



28 PHYSICAL DIAGNOSIS. 

when communicated through the medium of the air. 
The slightest change in pitch and quality is also readily 
appreciated. 

The benefits claimed for auscultatory percussion by its 
originators are : " First. That the heart can be measured 
in all but its antero-posterior diameters, under most, 
perhaps all circumstances of health and disease, with 
hardly less exactness than we should be able to do if the 
organ were exposed before us. 

" Second. That the outlines of the fiver can be traced 
with much greater certainty than by ordinary percus- 
sion, in circumstances of health ; and to circumscribe it 
in many conditions of disease in which ordinary percus- 
sion is not applicable. 

" Third. That the dimensions of the spleen can be 
ascertained in circumstances that baffle ordinary per- 
cussion. 

"Fourth. That by it we can mark the superior, infe- 
rior, and external limits of the kidneys. Ascites pre- 
sents no obstacle to the measurement of these organs ; 
and from enlarged spleen the left kidney is easily dis- 
tinguished." 

Succussion is the sudden, forcible shaking of the pa- 
tient while your ear is applied to the chest wall. It is 
employed almost exclusively in the diagnosis of one dis- 
ease, viz., pneumo-hydro thorax. The sound produced 
resembles that perceived on shaking a bottle, partly filled 
w4th water, close to the ear. It is a gurgling, splashing 
sound, and varies in tone according to the density of the 
fluid present and the relative quantities of fluid and air 
present. Succussion is almost always accompanied by 
amphoric respiration and metallic tinkling. I shall re- 
serve its further consideration until I detail the physical 
signs of pneumo-hvdrothorax. 



LESSOR IV. 

AUSCULTATION. 

Auscultation is a kind of eavesdropping, for in it 
you bend your ear to catch the significance of sounds 
that come from hidden quarters which no one may 
open. As in percussion, so here, auscultation may be 
immediate, when the ear is applied directly to the bared 
or thinly covered surface ; and mediate, when the sounds 
are conducted from the surface to the ear through a tu- 
bular instrument, called a stethoscope. 

Both of these methods have their exclusive advocates, 
but, as each has its own advantages, I would strongly 
recommend your becoming equally practised in the use 
of them both. Per se, immediate auscultation answers 
best for pulmonary examinations ; but in examining 
the heart, where, as in valvular murmurs, you have to 
analyze circumscribed sounds, your ear will often be 
confused by the noise of its near neighbor, the left lung, 
or by other cardiac sounds than the one under exami- 
nation, and you will find the stethoscope then assists 
you by measurably excluding the sounds which have 
their seat outside the rim of the chest piece. Besides, 
there are cases where the state of the surface may make 
you very reluctant to bring your ear into immediate 
contact with the patient's person, while in other cases 
you may not be allowed to do so, and in such, of course, 
you would have recourse to the stethoscope. 

Stethoscopes of great variety as to form and material 



30 PHYSICAL DIAGNOSIS. 

have been recommended, each inventor claiming some 
superiority in principle, or shape, for his own instrument. 
They may all. however, be referred to two general 
classes, viz. , flexible and solid. I regard as the best rep- 
resentatives of these two classes those devised by the 
late Dr. Cammann, of this city. For general use I 
would recommend his Binaural Stethoscope. It con- 
sists of two tubes, the lower extremities of which are 
connected to a cup -shaped piece of wood or hard rubber. 
It requires some practice to become adepts in its use, as 
it indiscriminately intensifies all sounds ; but once ac- 
customed to it, you will find, I think, it has no superior. 

In the performance of auscultation, as of percussion, 
certain precautions are requisite in order to insure accu- 
rate results. The following rules will be found of ser- 
vice : 

First. In immediate, but not in mediate auscultation, 
the chest should have some thin, soft covering which 
will not interfere with the transmission of sound, or it- 
self produce sound from the movements of the thoracic 
walls to which it is applied. A soft towel smoothly 
spread over the surface will answer this purpose very 
well. 

Second. The position of the patient should be regu- 
lated in the same manner as for the performance of in- 
spection, care being taken that the parts should be in a 
state of perfect repose. The position of the examiner 
should be as unrestrained as possible, and he should by 
all means learn to concentrate his attention on the 
sounds which reach his ear. 

Tliird. The ear, or the stethoscope, should be applied 
firmly, but not forcibly, to the surface ; and, when the 
stethoscope is * used, it is important that its rim press 
equally and evenly on the part. 



AUSCULTATION. 31 

Fourth. As in percussion, corresponding parts of the 
two sides of the chest should be compared, and the ex- 
amination should not be considered complete unless it 
has included the entire chest. In acute thoracic affec- 
tions auscultation should be frequently repeated. 

Fifth. The examination should be commenced, if pos- 
sible, during ordinary respiration. The patient should 
be directed to take a full inspiration, then to cough, and 
then again to breathe naturally. Some find the latter 
very difficult, when under examination, and they some- 
times seem incapable even of completing a full inspira- 
tion. In such instances, our object may be attained by 
performing the act ourselves, and requesting the patient, 
to imitate it, or by directing him to sigh. If these expe- 
dients fail, direct him to cough continually for some 
moments, whereupon a full, clear inspiration follows, 
and he does involuntarily what his previous efforts have 
failed to accomplish. 

Let us now consider the important subject of the na- 
ture and causes of the respiratory sounds in health. 

If the ear be applied to a healthy chest, a soft, breezy 
murmur will be heard, composed of two periods — one 
corresponding to the movements of inspiration, and the 
other, both fainter and shorter, to those of expiration. 
They are termed, respectively, the inspiratory and the 
expiratory sounds of respiration. The elements of these 
sounds are analogous to those of percussion, and, hence, 
we express them by the terms Intensity, Pitch, Quality, 
and Duration, to which, however, we add a fifth — 
Rhythm — which refers to the relative succession of the 
two periods in the respiratory act. As might be ex- 
pected, we find variations among these elements, nor- 
mally present in the various portions of the respiratory 
tract, and these constitute distinct varieties of respira- 



32 PHYSICAL DIAGNOSIS. 

tory sounds, which are named after those portions in 
which they occur in health. Thus we speak of vesicu- 
lar, bronchial, tracheal, and laryngeal respiration, each 
of these sounds having its own proper intensity, quality, 
pitch, etc. The left infra-clavicular region in a healthy 
chest furnishes the purest vesicular respiration ; the 
inter- scapular region, the best normal bronchial respira- 
tion ; and by placing the stethoscope or ear over the 
larynx or trachea, you will hear the tracheal and laryn- 
geal breathing. These variations in the intensity, pitch, 
etc., are due to differences in the volume and velocity of 
the current of air, on the one hand, and, on the other, 
to the nature of the obstructions which it meets in its 
entrance to, or exit from, the pulmonary passages. 
Every complete respiratory sound, however, retains its 
division into inspiratory and expiratory murmurs. 

Of the normal respiratory sounds, that which stands 
first in importance is the Vesicular. The best represen- 
tative type of the normal vesicular murmur is found in 
the left infra-clavicular space, where you will hear dur- 
ing inspiration a sound of a gentle rustling character, 
most marked at the end of the act. The intensity and 
duration of this murmur vary in healthy persons, and 
form the least important of its elements. Its pitch, 
however, should be low. The expiratory sound, when 
present (it being absent in four out of five healthy 
persons when their attention is not directed to their re- 
spiration), is much shorter than the inspiratory, its rela- 
tive duration varying in different individuals ; its in- 
tensity is less than in inspiration, its pitch higher, and 
its quality harder ; the breezy or vesicular character of 
the inspiratory sound being wanting. These two sounds 
follow each other so closely that they may be said to be 
continuous, and this fact is itself an important element 



AUSCULTATION. 33 

of normal vesicular respiration. It should be noted 
here, however, that the normal respiratory sounds do 
not exactly correspond in the two infra-clavicular re- 
gions. On the right side, the pitch of the inspiratory 
sound is higher than on the left, and less breezy in 
quality, while the expiratory is more pronounced and 
prolonged in duration. This disparity should be taken 
into account in all doubtful cases, such as in suspected 
small pulmonary consolidations. Age affects the char- 
acter of normal vesicular respiration, taking for the 
standard of comparison the respiratory sounds in healthy 
middle aged individuals. In infancy the intensity of 
both the inspiratory and expiratory sounds is increased, 
while the other elements remain the same. In old age, 
on the other hand, the intensity is diminished, the du- 
ration of the inspiratory sound shortened, and the ex- 
piratory prolonged. Sex also modifies the respiratory 
sounds. As a rule, the inspiratory and expiratory 
sounds have greater intensity in the female than in the 
male. The greatest intensity is in the upper anterior 
portions of the chest in the female, while in the male it 
is most marked in the lower and posterior portions. 

If the ear or stethoscope be applied to the larynx or 
trachea, two sounds will be heard, one with inspiration, 
the other with expiration. These sounds constitute the 
normal laryngeal and tracheal respiration. It differs 
from the normal vesicular respiration in that its in- 
tensity is increased, its pitch raised, and its quality 
wholly tubular. The inspiratory sound does not con- 
tinue quite to the end of the inspiratory act, so that an 
interval occurs between it and the expiratory sound. 

The characters of the next variety, or bronchial respi- 
ration, are very important to the auscultator from their 
common occurrence and significance in disease. They 
3 



34 PHYSICAL DIAGNOSIS. 

are those of tracheal respiration, only in a less marked 
degree, being less tnbular in quality, while the interval 
between the inspiratory and expiratory sounds is shorter. 
Now, the more thoroughly you learn these varieties 
of healthy respiration, the better you will be prepared 
to understand what respiratory sounds are abnormal. 
Very often you will hear in disease what you recognize 
as one of the normal sounds, but you know that this 
familiar sound has in this case a serious import, because 
it is not the natural sound of that locality. But you 
may also hear sounds whose character differs from any 
normal type. We may say, in general, that abnormal 
sounds consist in changes from the standard of healthy 
respiration as regards the three elements of intensity, 
rhythm, and quality, thus : 

_ _ .. . f 1. Exaggerated or increased. 

In Intensity the respira- I % Diminishe<J or feeble 

tory murmur may be . . | g Absent Q1 , suppressed 



In Rhythm the respira- 
tory murmur may be 



1. Interrupted. 

2. The interval between inspiration 
and expiration be prolonged. 

3. Expiration be prolonged. 

I 1. Rude, termed rude respiration. 

In Quality the respira- I 2. Bronchial, " bronchial " 
tory murmur may be. . . j 3. Cavernous, " cavernous " 
[ 4. Amphoric, 4 ' amphoric " 

Alterations in Intensity. 

Exaggerated Respiration differs from the normal 
vesicular respiration only in an increase in the intensity 
and duration of the respiratory sounds. It is sometimes 
called puerile respiration, from its resemblance to the 
respiration of children. It occurs in a part where respi- 
ration is more active than usual, owing to cleficient ac- 
tion elsewhere, as in the upper part of one lung whose 



ALTERATIONS IN RHYTHM. 35 

lower lobe is consolidated by pneumonia, or similarly 
where one lung does the duty of its fellow which is solid- 
ified by the pressure of a pleuritic effusion. 

Diminished or Feeble Respiration differs from nor- 
mal vesicular respiration only in a diminution in the in- 
tensity and duration of the respiratory sounds. It may 
arise from any cause which interferes directly or indi- 
rectly with the expansion of the lung, or which dimin- 
ishes the elasticity of the alveolar walls. Of the first 
condition, we have illustrations in affections which re- 
strain the movements of the thoracic walls, as pleuritic 
pain, rheumatism, paralysis, etc. ; or when there is some 
obstruction to the entrance of air into the lungs, such as 
in diseases of the larynx, trachea, or bronchial tubes ; or, 
again, when a pleuritic effusion or a tumor presses the 
lungs back from the chest walls, though not to a degree 
sufficient to prevent all air from entering them. Of the 
second condition, we have examples in pulmonary em- 
physema and in incipient tubercular deposits. 

Absent or Suppressed Respiration occurs whenever, 
from some cause, the play of the lung is suspended. 
This may be either from external pressure, as when the 
lung is forced against the spinal column by the presence 
of fluid or air in the pleural cavity ; or when a complete 
obstruction of any bronchus prevents the air from either 
entering or leaving the lungs. 

Alterations in Rhythm. 

Interrupted Respiration.— In health the respiratory 
sounds are even and continuous, with a brief interval 
between each act. This may be altered in disease, and 
both sounds, especially the inspiratory, may have an 
interrupted or jerking character, termed by some "cog- 
wheel respiration." We have examples of this kind of 



36 PHYSICAL DIAGNOSIS. 

respiration in asthma, pleurodynia, first stage of pleurisy, 
and incipient phthisis. It is most frequently associated 
with phthisis, and may be due probably to some gelati- 
nous mucus adhering to the walls of the finer bronchial 
tubes, which, though not sufficient to produce rales, still 
obstructs the free ingress and egress of the air. This 
"cog-wheel" respiration occurs in some uervous individ- 
uals with normal lungs, especially in young girls. A 
quick, full inspiration will cause it to disappear. 

Prolonged Interval between Inspiration and Ex- 
piration. — Instead of the two sounds closely succeeding 
one another, they may be separated by a distinct inter- 
val. When this occurs, either the inspiratory sound is 
shortened, or the expiratory delayed in its commence- 
ment. In the first instance, it is the result of pulmonary 
consolidation, as in tubercle ; in the second, the elasticity 
of the pulmonary tissue is impaired, as in emphysema, 
no sound being heard during the first portion of the ex- 
piratory act. 

Prolonged Expiration. — Here the ratio between nor- 
mal inspiration and expiration is inverted. The ex- 
piration, at times, is twice or three times as long as the 
inspiration. 

It is always due to a want of freedom in the egress of 
air from the lungs. The most common, and therefore, 
practically speaking, the most important, cause of pro- 
longed expiration is tubercular deposit in the lung. Ex- 
cessively prolonged expiration is to be met with in vesic- 
ular emphysema, and this is to be distinguished from the 
prolonged expiration of phthisis by its pitch, which in 
emphysema is low, lower than the inspiration, while in 
phthisis it is high, higher than the inspiration, and tubu- 
lar in quality. 



ALTERATIONS IN QUALITY. 37 

Alterations in Quality. 

Rude Respiration. — This is termed by Prof. A. Flint 
broncho-vesicular respiration. In this variety both in- 
spiratory and expiratory sounds lose their natural soft- 
ness ; the breezy or vesicular quality is lost ; the sounds 
are higher pitched and more tubular in character, while 
the expiration has more intensity, higher pitch, and 
longer duration than the inspiration. Rude respiration 
always indicates more or less consolidation of lung tissue. 
In normal vesicular respiration, the sounds produced by 
the vibrations of the air in the air cells and finer bronchi 
obscure that produced in the trachea and larger bronchial 
tubes (healthy lung substance being a poor conductor 
of sound) ; but so soon as any portion of lung be- 
comes consolidated, the vesicular element of the respi- 
ratory sound is diminished and the bronchial element 
becomes prominent ; this change constitutes rude respi- 
ration. It embraces every degree of modification between 
complete bronchial respiration on the one hand and 
normal vesicular breathing on the other, the increase in 
bronchial characters corresponding with the degree of 
consolidation. Rude respiration is of practical value 
principally in the diagnosis of incipient phthisis. 

Bronchial Respiration is characterized by an entire 
absence of all vesicular quality. The inspiratory sound 
is high-pitched and tubular in character ; the two sounds 
are separated by a brief interval ; the expiratory is still 
higher pitched and more intense than the inspiratory, is 
as long or longer, and of the same tubular quality. 
Whenever this modification of the respiratory sound is 
present, where in health normal vesicular murmur should 
be heard, consolidation of lung substance may be in- 
ferred. Consequently it is an important diagnostic sign 



38 PHYSICAL DIAGNOSIS. 

in many pulmonary affections, such as pneumonia, pul- 
monary tuberculosis, pulmonary apoplexy, etc. 

Cavernous Respiration. —In some respects this re- 
sembles bronchial respiration, and it is often difficult to 
distinguish one from the other. Some distinguished 
auscultators declare that this sign does not exist. 

Its distinguishing characteristics are, on inspiration, a 
soft, blowing, low-pitched sound, non- vesicular in cha- 
racter : as a rule, the expiratory sound is lower pitched 
than the inspiratory, and is always prolonged and 
puffing. 

For its production, there must be a cavity of consider- 
able size in the lung substance, having free communica- 
tion with a bronchial tube. The cavity must be empty 
and near the surface, its walls must be sufficiently flaccid 
to expand with inspiration, and collapse with expiration. 
This sign is most frequently met with in the advanced 
stage of pulmonary tuberculosis. 

Amphoric Respiration. — Whenever the respiratory 
sound has a musical intonation or metallic quality, re- 
sembling that produced by blowing gently into the mouth 
of an empty bottle, it is called amphoric. 

The amphoric character accompanies both acts of res- 
piration, especially the expiratory. 

It may be due to phthisical or other excavations in the 
lung substance, or to an opening from the bronchial tube 
into the pleural cavity, giving rise to pneumothorax. 
In both cases the sound is produced by vibrations of air 
in a cavity, which are excited by a current of air from a 
bronchial tube. The cavity in the lung substance which 
gives rise to amphoric respiration must be of large size, 
empty, with tense, firm walls so as not to collapse with 
expiration, and it must communicate freely with a large 
bronchial tube. 



1XTRA-THORACIC AUSCULTATION. 39 

This sign is mainly of importance in the diagnosis of 
advanced tuberculosis and pneumothorax. 

This completes the history of the most important 
alterations in the natural respiratory sounds produced 
by disease. With few exceptions they are not new 
sounds, but are heard in the healthy chest, and become 
significant of disease only when heard in unnatural 
locations. 

A new method of auscultation has recently been proposed by 
Dr. B. W. Richardson (vide Lancet, November 5th, 1892). It is 
termed ' ' Intra-thoracic Auscultation : A New Departure in Physical 
Diagnosis." He employs "a good-sized [oesophageal] tube with a 
large lateral aperture at the extreme end. Apertures are essential 
in these tubes; if they are not made, there is little or no conduction 
of sound." The free end of the tube is connected to an ordinary 
binaural stethoscope. Dr. Richardson claims that by this means 
an early diagnosis of stricture of the oesophagus can be made from 
the friction sound produced as the tube passes over the induration, 
and that it may be of service in the diagnosis of diseases of the stom- 
ach itself ; that, through the stomach, pulsating abdominal tumors 
could be diagnosed : ' 'with the terminal of a full-sized oesophageal 
stethoscope in the stomach cavity, a loud murmur from an arterial 
source will be detected without the interposition of pressure, and an 
important difficulty in diagnosis removed" ; and that this method 
will prove of service in the diagnosis of diseases of the heart and 
aneurisms of the large thoracic arterial trunks. In concluding he 
says : "I assume at once that this mode of research is not called for 
when by the ordinary auscultation diagnosis is clear." 

I have not tried this method of examination, and therefore cannot 
recommend it from personal experience. 



LESSON V. 

ABNORMAL OR ADVENTITIOUS SOUNDS. 

The sounds which are now to be considered are termed 
Adventitious, because they are not heard in health, but 
are found in disease, either accompanying the normal 
respiratory sounds, or wholly supplanting them. They 
vary much in their character, according to their origin, 
that is, whether they are caused by changes in the lung 
itself or in its investments ; and, hence, in order to ap- 
preciate their significance you should know well their 
seat and mode of production. 

The sounds which originate in the air passages, or 
in cavities abnormally communicating with them, are 
called rales, or rhonchi : those which originate in the in- 
vestments of the lung are called pleuritic friction sounds. 
In speaking of the former I shall use the term rale, and 
would classify the varieties which we meet in practice 
as follows : 



Drv rales. 



\ Sonorous rales, 
i Sibilant rales. 



Mucous rales (large and small). 
Rales, i ; Sub -crepitant rales. 

Moist rales. \ Crepitant rales. 

J Gurgles (large and small). 
[ Mucous click. 

A rale may originate in the trachea, in the bronchi, 
large or small, in the air cells, or in abnormal cavities 
situated either within or without the lung substance. 



RALES. 



41 



It may be produced within the air tubes, either by a 
diminution of their calibre, by the vibrations of viscid 
matter collected in them, or by the air bubbling through 
fluid present in the bronchi and in the air vesicles, or in 
larger or smaller cavities. A rale may be either dry or 
moist in its character, and may be audible either in in- 
spiration or in expiration, or in both. 

Dry Eales are divided into sibilant, and sonorous ac- 
cording to the pitch and quality of the sound ; if a rale 




Fio. 



-Diagram illustrating the Physical Signs of Bronchitis. 



is high-pitched and whistling, it is termed sibilant ; if 
low-pitched and snoring in character, it is termed sono- 
rous. 

The Sibilant rale may be heard during both inspira- 
tion and expiration. It recurs irregularly, and some- 
times is so high-pitched as to become hissing in its char- 
acter. Its seat is the smaller bronchi, and it is caused 
either by the narrowing of these tubes from thickening 
of the mucous tissues lining them, or from the spas- 
modic contraction of their muscular coat ; or it may be 



42 PHYSICAL DIAGNOSIS. 

owing to the vibrations of viscid mucus adhering to 
their walls. In most instances it may he temporarily 
removed by violent coughing. 

The Sonorous rale may also be heard during both in- 
spiration and expiration. As above mentioned, it is a 
low-pitched, snoring sound, which varies, however, in 
intensity from a slight rale to one loud enough to be 
audible at a distance from the chest. It has for its seat 
the larger bronchial tubes, and is produced by conditions 
of those tubes similar to those which cause sibilant rales 
in the smaller bronchi, namely, lessened calibre from 
tumefaction of the mucous tissues, or from spasmodic 
contraction, or from pressure on the tube from without, 
by a tumor, an exudation, or a deposit ; or it may be 
owing to the vibrations of a thickened fold of the lining 
membrane, or of viscid mucus adhering to the wall. 
This rale is specially frequent in bronchitis and spas- 
modic asthma, though it may be present in almost every 
pulmonary disease. 

Moist Eales. — Under this head may be included the 
crepitant, sub-crepitant, and mucous redes. 

Crepitant rales consist of a series of minute, crackling 
sounds. They persist at the spot where first heard, 
and do not shift their position as the other moist rales. 
They are audible only toward the end of inspiration. 
There are several views as to the production of these 
sounds : that they are due to the bubbling of air through 
a liquid in the pulmonary vesicles or terminal bronchi- 
oles ; that, at the end of expiration, a viscid secretion 
glues the walls of the vesicles together, and their sepa- 
ration on inspiration gives rise to the crackling sound ; 
and that they are produced in the pleura independently 
of the pulmonary parenchyma. This rale is the charac- 
teristic sign of pneumonia in the first stage, though it is 



RALES. 43 

not infrequent in some forms of pulmonary congestion, 
and in oedema of the lungs. v 

The Sub-crepitant rale is a moist bronchial sound, 
caused by the breaking of minute air bubbles of equal 
size and comparatively few in number. Its seat is the 
smallest bronchi, and the liquid through which the air 
passes may be mucus, serum, pus, or blood. It differs 
from the crepitant rale in the larger size of the bubbles, 
and is heard in expiration as well as in inspiration. This 
rale is present in a number of affections. When heard 
on both sides of the chest posteriorly, it indicates capil- 
lary bronchitis. It is characteristic of the resolving stage 
of pneumonia, and is termed the "rale redux.*' When 
present only in the apex of a lung, it indicates commenc- 
ing tuberculosis. It accompanies the effusion of blood 
into the bronchial tubes, and is sometimes present in 
oedema of the lungs. 

The Mucous rale is a moist bronchial sound, produced 
in the same manner as the sub-crepitant. Its seat is in 
the larger tubes, and, according to the size of the tube 
in which the sound originates, it ii termed the fine or 
coarse mucous rale. Like the sub-crepitant rale, you 
may hear it during both inspiration and expiration, and 
it is modified, or entirely removed, by the act of cough- 
ing. Mucous rales occur in bronchitis during the stage 
of secretion ; in bronchial haemorrhage ; whenever pus 
makes its way into the air passages from an abscess— 
in short, whenever the bronchial tubes become partially 
filled with liquid of any kind. If these rales, whether 
fine or coarse, are restricted to a circumscribed space at 
the apex of a lung, they indicate that the bronchitis is 
of tubercular origin. 

Gurgles are produced in large or small cavities partly 
filled with liquid, below the level of .which a bronchus 



44 



PHYSICAL DIAGNOSIS. 



freely opens. The sound is due to the bubbling of air up 
through the liquid. It is a moist sound, but has a pe- 
culiar hollow, metallic quality. Gurgles may be heard 
both in inspiration and expiration, and according to 
the size of the cavity will they be " large" or " small." 
Small gurgles resemble large mucous rales, but may be 
distinguished from them by their above-mentioned hol- 
low, metallic character. 

The most frequent cause of pulmonary cavities is the 




Gurgles. 



—Cavernous 
respiration. 



Fig. 4.— Cavernous Respiration and Gurgles 

softening and expectoration of a cheesy pneumonia, but 
they may be owing to abscess, gangrene, perforating 
empyema, and excessive dilatation of the bronchial 
tubes. When pulmonary cavities exist without gurgles, 
it may be due to the filling of the cavity with liquid, or 
to its containing no liquid, or because the level of the 
liquid is below the opening of the bronchial tube. 

Mucous Click. — This is a single, quick, clicking sound, 
not removed by coughing, and which resembles an iso 
lated sub-crepitant rale. Authors differ as to the theory 



PLEURITIC FRICTION SOUNDS. 



45 



of its production. It appears to me to be due to the sud- 
den and forcible passage of air through a small bron- 
chus, the sides of which have been brought together at 
one or more points, either by external pressure or by ag- 
glutination from within ; as when a consolidated lobule 
presses unequally upon a bronchus, and excites a local 
inflammation of the mucous membrane with its con- 
sequent viscid secretion. It is therefore important as a 
symptom of incipient tuberculosis. 



Pleuritic friction sound 



Flatness on percus- 
sion. Absence of vo- 
cal and respiratory- 
sounds. 




Fig. 5.— Roughening of the Pleura?, and Slight Pleuritic Effusion. 



Pleuritic Friction Sounds. — In health the smooth 
pleural surfaces, moistened by their natural secretion, 
play noiselessly upon each other during the respiratory 
movements. When an inflammation roughens one or 
both of these surfaces, or dries up their natural secretion, 
it gives rise to a friction which produces the charac- 
teristic sounds to which the above name is given. 
These sounds consist of one or of a series of 
abrupt, jerking, rubbing noises, manifestly superficial, 



46 PHYSICAL DIAGNOSIS. 

and which are commonly heard over a limited extent of 
surface. They vary much in intensity, from a sound 
scarcely audible to one of extreme loudness ; and they 
usually accompany both inspiration and expiration, be- 
ing seldom heard with expiration alone. 

There are several varieties of pleuritic friction sounds, 
termed, respectively, grazing, rubbing, grating, creak- 
ing, and crackling ; all of which belong to the clinical 
history of pleurisy. 

The grazing variety occurs at the onset of pleurisy, 
when dryness of the membrane is the only change yet 
produced. As soon as there is dulness on percussion, it 
is replaced by the rubbing variety, and therefore is of 
such short duration that it is not often heard, but may 
be more frequently noticed in the circumscribed pleurisy 
which often accompanies pulmonary tuberculosis. The 
other varieties are the forms in which the pleuritic fric- 
tion sound most commonly presents itself ; and they 
occur both in the stage of plastic exudation and in the 
stage of absorption. 

Sometimes the respiratory sound is attended by sounds 
resembling rales, which are doubtful both as to their 
situation and significance. 

They are of two kinds : First, creaking sounds not in- 
frequently heard at the apices of the lungs, produced 
either by the creaking of pleuritic adhesions or by crepi- 
tations in lung tissue. Second, dry crumpling sounds, 
resembling those produced by inflating a dried bladder, 
probably (as Laennec supposed) produced by the forcible 
distention of large air sacs in emphysematous lungs. 



LESSOR VI. 

AUSCULTATION OF THE VOICE. 

This is another method of obtaining information as to 
the condition of the lungs and their investing mem- 
branes. It is based on the fact that the vibrations of the 
voice are not transmitted upward only, but also down- 
ward, through the trachea and bronchi, to all parts of 
the lung. The resonance thus produced varies in cha- 
racter according to the situation in which it is heard. 
The different varieties are named after the parts where 
they occur in health. 

If the stethoscope be placed over the larynx or tra- 
chea of a healthy person while speaking, the voice will 
be transmitted to the ear, imperfectly articulated, and 
with a force, intensity, and concentration almost pain- 
ful. This is called natural laryngophony or tracheo- 
phony. 

At the upper part of the sternum, and between the 
spines of the scapula, it is heard less intense, more dif- 
fused, and less distinctly articulated ; and this is termed 
bronchophony. But when you listen over the lung sub- 
stance itself, the voice sounds become distant, diffused, 
and without any approach to articulation. This is 
termed normal vocal resonance. Its intensity is usually 
greater on the right than on the left side, especially in 
the infra- clavicular region, but it varies considerably in 
this respect in different healthy persons. In females 
there is, not infrequently, no difference in the two sides. 






48 PHYSICAL DIAGNOSIS. 

The intensity over the whole chest is greater in those 
who have low-pitched voices, and in thin than in fleshy 
persons. You cannot rely on the vocal resonance of any 
one region of the chest as trustworthy evidence, by itself, 
either of health or of disease. Its indications are fur- 
nished only by comparisons of corresponding parts of 
the two sides, after allowance is made for natural dif- 
ferences. 

In making your examination for this purpose the read- 
iest way is to direct the patient to count one, two, three, 
or repeat the numeral 99. The modifications of the vo- 
cal resonance which you will find indicative of disease 
will consist of changes in intensity. 1. Its intensity 
may be diminished ; or, 2, it may be increased ; and I 
would classify them as follows : 

1. Diminished j a. Vocal sounds may be weak or feeble. 

intensity. \b. " " " suppressed or absent. 

a. Vocal sounds may be simply exaggerated. 

b. The resonance may be of the character termed 
Bronchophony. 

c. The resonance may be of the character termed 
Pectoriloquy. 

d. The resonance may be of the character termed 
Egophony. 

e. The resonance may be of the character termed 
Amphoric Voice. 

The varieties included under the head of diminished 
resonance require but little explanation. The vocal re- 
sonance may be faint or altogether wanting. The first of- 
ten occurs in bronchitis with free secretion ; in plastic 
pleuritic effusions, and, occasionally, when there is ex- 
treme pulmonary consolidation. There is absence of vo- 
cal resonance in pneumothorax and in copious serous 
pleuritic effusion. The modifications, however, which 
accompany increased intensity are more varied and com- 
plex. 



2* Increased 
intensity. 



VOCAL RESONANCE. 49 

Exaggerated Vocal Kesonance differs from normal 
vocal resonance only in a slight increase of intensity. It 
denotes a moderate amount of solidification of lung tis- 
sue, and is chiefly of importance in the diagnosis of tu- 
berculosis. 

The characters of Bronchophony, as contrasted with 
normal vocal resonance, are its greater intensity, higher 
pitch, peculiar vibrating quality, and approach to articu- 
lation of the voice sounds. When heard in abnormal 
situations it has the same significance as bronchial res- 
piration, though more complete consolidation is neces- 
sary for the production of bronchial respiration than 
bronchophony. The best example of bronchophony is 
met with in the second stage of lobar pneumonia. 

Pectoriloquy (so named by Laennec, its discoverer) is 
a complete transmission of the voice to the ear. The 
words spoken are heard distinctly articulated. It closely 
resembles the resonance heard over the larynx, and is 
usually limited to a small space in the chest, where it 
also may, or may not, have a hollow, ringing character. 
It was formerly believed always to indicate the presence 
of a pulmonary cavity, but auscultators are now agreed 
that this is not necessarily the case in every instance, but 
that it is sometimes simply an exaggerated broncho- 
phony ; the only distinction between these two being 
that bronchophony is the transmission of the voice, pec- 
toriloquy that of the speech. Well-defined pectoriloquy 
is not a common phenomenon. 

Egophony is the name given by Laennec to another 
form of vocal resonance, which is distinguished by its 
tremulous, nasal character, suggestive of the bleating 
of a goat. It also is a modification of bronchophony. 
Laennec considered it a sign of a limited amount of 
serous effusion in the pleura, over solidified lung. It 



50 PHYSICAL DIAGNOSIS. 

is rarely heard, and is of not much significance when 
heard. 

Amphoric Voice is a term applied to the vocal reso- 
nance whenever, in addition to its being of a hollow, 
metallic character, it has a distinct musical intonation. 
This musical sound follows the voice, is of high pitch, 
and is not articulated like pectoriloquy. It is sometimes 
produced in large cavities within the lung, but is more 
particularly a sign of hydro-pneumothorax. 

In addition to vocal resonance, we have a true whisper 
resonance, the modifications of which by disease may 
afford us some valuable hints (as was first pointed out by 
Prof. A. Flint). If, while practising auscultation on a 
person in health (as I should strongly advise you to do 
with one another while studying this subject), you direct 
him to count in a loud whisper, you will usually hear a 
soft, blowing sound, accompanying each whispered word, 
which varies in intensity in different persons. 

As a rule, it is heard only at the upper portion of the 
thorax, and is loudest over the primary bronchi. Dr. 
Mint calls this sound the normal bronchial whisper, and 
he classes its abnormal modifications into exaggerated 
bronchial whisper, whispering bronchophony, whispering 
pectoriloquy, cavernous whisper, and amphoric whisper. 

The exaggerated differs from the normal whisper in 
having greater intensity and higher pitch. It indicates 
slight solidification of lung tissue. In whispering bron- 
chophony, the blowing sound is intense, the pitch high, 
and the sound seems near to the ear. When heard in 
situations Avhere it is not normally present, it indicates, 
like vocal bronchophony, more or less complete consoli- 
dation of the lung substance. The cavernous whisper is a 
hollow, low-pitched, blowing sound. It is a trustworthy 
indication of a cavity, and requires for its production 



RESONANCE OF COUGH. 51 

conditions similar to those which give rise to cavernous 
respiration. In whispering pectoriloquy, the whispered 
words are distinctly audible at the surface of the chest, 
and this constitutes a more sure indication of a cavity 
than vocal pectoriloquy. The character and the signi- 
ficance of the amphoric whisper are the same as those 
of the amphoric voice. 

Another of the adventitious sounds is that which is 
termed metallic tinkling, its name being sufficiently de- 
scriptive of its character. It sounds like the dropping of 
a pin or a small shot into a metallic vessel. A single 
one, or a series of tinkling sounds, may be produced by 
the act of speaking, or by the movements of inspiration 
and expiration ; but it is especially consequent on the 
act of coughing. 

This sound announces the existence either of a very 
large pulmonary cavity or of hydro-pneumothorax. Dr. 
Walsh regards it as the echo of a bubble bursting in a 
liquid, shut up in a spacious cavity which also contains 
air. 

Resonance of Cough. — In a healthy individual, the 
act of coughing is accompanied by a quick, sharp, in- 
distinct sound, which jars through the whole chest. 
Over the larynx and trachea the cough is hollow, and 
varies in pitch and intensity with the voice of the in- 
dividual. The modifications of the cough sound in dis- 
ease are termed bronchial, cavernous, and amphoric. 
Bronchial cough has a quick, harsh character, attended 
by a marked thrill or fremitus of the chest. Cavernous 
cough is hollow and metallic (commonly it is termed 
sepulchral). It may be accompanied by gurgles, and its 
resonance is sometimes transmitted to the ear of the 
auscultator with painful intensity. Amphoric cough is 
a loud resounding sound, of metallic character, but not 






52 PHYSICAL DIAGNOSIS. 

forcibly transmitted to the ear. It conveys the impres- 
sion of a large empty space. These varieties of cough 
are heard under the same conditions as the correspond- 
ing varieties of respiration. They are not of much 
utility in diagnosis. 



LESSOR TIL 

A SYNOPSIS OF PHYSICAL SIGNS IN THE DIAGNOSIS OF 
PULMONARY DISEASES. 

Bronchitis. 

Acute and Chronic Bronchitis affecting the Larger 

Tubes. 

Inspection. — The form and movements of the chest 
are not visibly altered. 

Palpation. — Vocal fremitus is normal ; occasionally 
a distinct bronchial fremitus is communicated to the sur- 
face of the chest. 

Percussion. — Pulmonary resonance is normal, unless 
there is a very considerable accumulation of mucus in 
the bronchial tubes, in which case the normal resonance 
is diminished in the lower and posterior regions. 

Auscultation. — The respiratory murmur is feeble or 
temporarily suppressed in the lung tissue correspond- 
ing to the affected tubes. In the dry stage, sibilant 
and sonorous rales may be heard on both sides of the 
chest (as shown in Fig. 3). In the stage of secretion, 
along with the sibilant and sonorous rales, mucous rales, 
large and small, are heard on both sides of the chest (see 
Fig. 3). These rales are inconstant, coming and going, 
and changing their situation. When the rales are intense 
and abundant, they altogether mask the respiratory mur- 
mur. In some cases of slight bronchitis of the larger 
tubes, there are no distinct rales, but the respiration has 
a sonorous character. 

The Vocal Resonance is normal. 



54 PHYSICAL DIAGNOSIS. 

Capillary Bronchitis. 

Capillary Bronchitis, or bronchitis affecting the ulti- 
mate, or capillary, bronchial tubes. 

Inspection and Palpation give the same signs as in 
simple bronchitis. 

Percussion is normal, or it may be slightly exag- 
gerated. 

Auscultation shows, if the disease is extensive, that 
the vesicular murmur is weakened or suppressed. In its 
stead, sub-crepitant rales are heard on both sides of the 
chest, accompanied by sibilant rales of a markedly hissing 
character. 

The Vocal Resonance is normal. 

Differential Diagnosis of Bronchitis. — The diagnosis 
of bronchitis of the larger tubes is readily made. Some- 
times, however, the gravitation of fluid from the larger 
to the smaller tubes may give rise to sub-crepitant rales 
over a circumscribed area posteriorly. 

Capillary bronchitis may be confounded with pneu- 
monia, and with acute or chronic tuberculosis. It is dis- 
tinguished from pneumonia by its normal or exaggerated 
resonance on percussion, by the existence of sub-crepitant 
rales on both sides of the chest, and by the absence of 
bronchial breathing. The diagnosis of capillary bron- 
chitis from tuberculosis will be considered under the head 
of the latter. 

If the sub-crepitant rales are confined to the apex or 
base of one lung, and there is resonance on percussion, 
the bronchitis is either of a tubercular or emphysematous 
origin. 

Dilatation of Bronchi. (Bronchiectasis.) 

Bronchiectasis is usually associated with fibrous in- 
duration of the lung or with emphysematous enlarge- 



PULMONARY EMPHYSEMA. 55 

ment, and is recognized by the following physical 
signs : 

Inspection shows defective expansive movements of 
the chest, and prolonged, labored expiratory movements. 

Palpation. — Vocal fremitus varies, rhonchial fremitus 
frequently present. 

Percussion is amphoric, unless the accumulation of 
thick secretion gives rise to obstruction of the tubes, and 
consequent local solidification of the lung ; in such cases 
there is temporary dulness. This dulness is to be distin- 
guished from the dulness of pneumonia by its tempo- 
rary character, and by the variations in vocal fremitus. 
From pneumonic consolidation it is distinguished by the 
presence of cavernous and amphoric breathing. 

Auscultation. — The results of auscultation vary ac- 
cording to the condition of the cavity. When it is full, 
the respiratory sounds are more or less deficient over por- 
tions of the chest ; when it is empty, they become harsh 
and loud. They are accompanied by a variety of rales, 
chiefly sonorous. But after profuse expectoration, large 
mucous rales or gurgles may be present. The sounds in 
any portion of the lung are constantly changing in cha- 
racter, altered by cough or a full inspiration. 



Pulmonary Emphysema. 

Inspection in a well-marked example of this disease 
reveals alterations in the shape and movemeDts of the 
chest. The sternum is often abnormally prominent, as 
if from congenital deformity. There is bulging of the 
infra-clavicular and mammary regions, which gives to 
the upper portion of the chest a more rounded appearance 
than in health, or, as it is called, "barrel-shaped." The 
shoulders are elevated and brought forward ; there is 



56 PHYSICAL DIAGNOSIS. 

more or less anterior curvature of the spine, and the 
person appears to stoop. The lower portion of the chest 
seems contracted, and the intercostal spaces are widened 
in the upper, narrowed in the lower spaces. In some 
instances in which the general symptoms of emphysema 
are well marked, the lung is atrophied instead of being 
abnormally dilated, and no bulging or prominence of the 
chest occurs, either general or local. 

The movements of the chest walls are also altered. 
At the upper portion, expansion on inspiration is dimin- 
ished or entirely wanting. The whole chest moves ver- 
tically up and down with inspiration and expiration, as 
if it were passively lifted from the shoulders and com- 
posed of one solid piece ; while below, the chest, instead 
of being dilated with inspiration, is contracted. 'The 
respiratory efforts are labored, and the breathing is 
chiefly abdominal. 

Palpation. — The vocal fremitus varies ; it may fall 
below, it may equal, or exceed, the average of health. 
The apex beat of the heart is often not perceptible in the 
precordial space ; sometimes it is felt much lower than 
its normal position. 

Mensuration shows a marked increase in the antero- 
posterior diameter of the chest. 

Percussion. — The intensity of the percussion sound is 
increased, the pitch is lowered, the pulmonary quality of 
the sound is greatly diminished, and it becomes what has 
already been described as vesiculo -tympanitic. The per- 
cussion note is not materially affected either by forced 
inspiration or forced expiration. 

Auscultation. — As a rule, the inspiratory sound is 
either short and feeble, or actually suppressed, and the 
expiratory sound is greatly prolonged : the ratio of the 
two sounds being as 1 : 4 instead of 4":i. The pitch of 



SPASMODIC ASTHMA. 57 

both inspiratory and expiratory sounds is lower than in 
health. 

In some extreme cases of emphysema, the respiratory 
sounds are of equal length, greatly exaggerated in inten- 
sity, and of a harsh, sibilant quality, the harsh quality, 
undoubtedly, being due to diminution in the calibre of 
the minute bronchial tubes. 

Vocal Resonance varies greatly ; sometimes it is di- 
minished or altogether absent ; at others its intensity is 
greatly increased. The heart sounds are feeble, and in 
rare instances the organ is pushed downward toward 
the epigastrium. 

Differential Diagnosis. — The only disease with which 
emphysema is liable to be confounded is pneumo- 
thorax. The distinction, however, is not very difficult, 
for in emphysema the percussion sound, although tym- 
panitic, still retains a pulmonary quality, and there is 
a vesicular element to the respiratory sound ; while in 
pneumothorax the percussion sound has a complete 
tympanitic character, and the respiration, if audible, is 
amphoric. Besides, pneumothorax affects only one 
side, emphysema both. 

Spasmodic Asthma {during the Paroxysm). 

Inspection shows labored respiration. 

Palpation, vocal fremitus normal. 

Percussion is normal or exaggerated. 

Auscultation. — The rhythm of the respiratory mur- 
mur is jerking and irregular ; sometimes it is exagge- 
rated, at others it is suppressed. Sibilant and sonorous 
rales, of a high-pitched, hissing and wheezing charac- 
ter, are diffused over the whole chest, often loud enough 
to be heard at a distance. 

Vocal Resonance is normal. 



58 



PHYSICAL DIAGNOSIS. 

Acute Lobar Pneumonia. 



The physical signs of pneumonia vary with its differ- 
ent stages. 

First Stage, or Stage of Engorgement. Inspec- 
tion. — The movements of the affected side a,re more or 
less restrained. 



1st Stage. 



j Slight dulness. 
( Crepitant rale 



f Complete dulness. . . 
) Bronchial respiration. , 

1 Bronchophony 

Increased vocal fremitus 



Diminished dulness. . . 
Sub-crepitant rale. . . 
3d Stage. "\ Broncho-vesic respiration. 
Increased vocal resonance 
Increased vocal fremitus. 



1 




Fig. 6.— Diagram illustrative of the Physical Signs of the three stages of Pneumonia. 

Palpation. — Vocal fremitus is slightly increased on the 
affected side. 

Percussion. — There is slight dulness over so much of 
lung tissue as is involved in the pneumonic inflamma- 
tion, the degree of dulness depending upon the amount 
of exudation into the lung substance. 

Auscultation. — In the early period of engorgement, 
before the exudation takes place, the respiratory mur- 
mur is diminished in intensity in the affected part, and 
exaggerated in other portions of the affected lung, as 



ACUTE LOBAR PNEUMONIA. 59 

well as ill the healthy lung. As soon as exudation takes 
place into the air cells, or on the pleural surface, the 
crepitant rale may be heard toward the end of in- 
spiration. It is the characteristic sign of the first stage 
of pneumonia. In some cases, especially when pneumo- 
nia is developed in connection with acute articular rheu- 
matism, crepitation never occurs. 

Second Stage, or Eed Hepatization. Inspection. — 
The expansive movements are diminished on the af- 
fected side, and increased on the healthy. 

Palpation. — As a rule, vocal fremitus is increased; 
occasionally it is diminished. 

Percussion. — Tfoere is marked dulness over a space 
corresponding to the consolidated lung tissue, and in- 
creased resonance over the healthy portion of the af- 
fected lung. The relation of the resonance and dulness 
is not affected by a change in the position of the patient. 
Absolute dulness or flatness on firm percussion very 
rarely exists. 

Auscultation. — As the air cells become completely 
filled with exudation the crepitant rales cease, and bron- 
chial respiration is heard over the solidified lung tissue. 
The more complete the consolidation the more intense 
and tubular is the bronchial respiration. 

Vocal Resonance. — There is marked bronchophony 
over all that portion of lung which is the seat of pneu- 
monic consolidation. The heart sounds are transmitted 
to the surface with unnatural intensity. The character- 
istic physical signs of this stage are dulness on percus- 
sion, bronchial breathing, and bronchophony. 

Third Stage, or Gray Hepatization.— The physical 
signs in the early part of this stage are the same as those 
of the second stage. They are simply the signs of con- 
solidation. In the latter or resolving part of this stage. 



60 PHYSICAL DIAGNOSIS. 

percussion shows progressive diminution in dulness. It 
is often, however, a long time before normal pulmo- 
nary resonance is perfectly restored. 

Auscultation. — The bronchial respiration of the sec- 
ond stage gradually gives place to rude (or broncho- 
vesicular) respiration, and this in turn approximates 
to, and at length ends in, normal vesicular breathing. 
As the bronchial respiration diminishes, the crepitant 
and sub-crepitant rales, or " rale redux," are developed, 
and remain audible until resolution is complete. Bron- 
chophony gives place to exaggerated vocal resonance, 
and that in turn to normal vocal resonance. The phy- 
sical signs of chronic pneumonia will be considered in 
connection with tuberculosis. 

Lobular Pneumonia. 

The areas of consolidation vary from the size of a pea to 
that of a hazelnut. They are usually scattered through- 
out both lungs, but in some instances isolated nodules 
may become confluent and the greater part of a lobe be 
consolidated. 

Lobular pneumonia is associated, as a rule, with a 
catarrh of the smaller tubes, and occurs most frequently 
in children and old people. 

Inspection. — In the severe lobular pneumonia of chil- 
dren, the respirations are hurried, shallow, and imper- 
fect. There is only slight expansion of the chest, or in 
some cases there may even be retraction of its lower 
portion during a full inspiration. In adults inspection 
reveals only an increased frequency of the respiratory 
acts. 

Palpation gives negative results unless the consoli- 
dated areas are of considerable size and situated near 
the surface of the lung. 



PULMONARY GEDEMA. 61 

Percussion. — Dulness is present over circumscribed 
areas. It may be slight or complete, depending upon 
the extent and location of the consolidation. 

Dulness in children can be elicited only by gentle per- 
cussion. 

On Auscultation small mucous rales, resembling the 
sub-crepitant, having a fine crackling and metallic cha- 
racter, are heard over the areas of dulness. They are 
audible both with inspiration and expiration. The breath- 
ing is at first feeble, but gradually it becomes broncho- 
vesicular, or even bronchial. The vocal resonance is in- 
creased : it may be bronchophonic. 

Differential Diagnosis. — Lobular pneumonia is most 
likely to be mistaken for capillary bronchitis. The dul- 
ness on percussion, the localization of the rales to cir- 
cumscribed areas, and the broncho- vesicular or bronchial 
breathing, will readily distinguish it. 

Pulmonary (Edema. 

In oedema of the lungs inspection and palpation fur- 
nish no positive information. 

Percussion. — There is more or less dulness on percus- 
sion (never, however, complete), diffused over the poste- 
rior surface of the chest on both sides, and marked at the 
most dependent portion of the lungs. 

Auscultation. — The respiratory murmur is feeble, 
sometimes almost entirely absent. With the inspiratory 
sound, crackling rales are heard over the seat of the 
oedema; the crackling resembles somewhat the crepi- 
tant rale of pneumonia, but is distinguished from it by 
its liquid character. 

Differential Diagnosis. — Pulmonary oedema may be 
confounded with the first stage of pneumonia, with hy- 
drothorax, and with capillary bronchitis. It is distill- 



62 PHYSICAL DIAGNOSIS. 

guished from pneumonia, as we mentioned above, by the 
liquid character of the crackling rales, and by its occur- 
ring on both sides, at the most dependent portions of the 
lungs, pneumonia usually being confined to one lung ; 
from hydrothorax, by the presence of rales, and by the 
level of the dulness not being changed by a change in 
the position of the patient ; from capillary bronchitis, 
by the slight dulness on percussion which attends it, 
and by the absence of the rales in the larger bronchial 
tubes. 

Pulmonary Gangrene. 

The physical signs of pulmonary gangrene are often 
obscure and never distinctive. They are those of local 
consolidation followed by the evidences of the breaking 
up of lung tissue and the formation of cavities in the 
lung substance. There are no special signs indicating 
the nature of the disorganizing process ; sometimes it is 
preceded by the signs of pneumonia ; generally it is ac- 
companied by the signs of bronchitis, and late in the 
disease there are physical evidences of the formation 
of cavities in the lung substance. 

Pulmonary Hcemorrhage. 

The physical signs of a slight haemorrhage from the 
lungs are very obscure. No information as to the seat 
or amount of the haemorrhage is furnished by inspection, 
palpation, or percussion. Auscultation may, however, 
indicate the spot at which the haemorrhage occurs, by the 
presence of moist rales. If the haemorrhage is profuse 
and accompanied by pulmonary apoplexy, abundant 
moist rales will be heard at the seat of the effusions, and 
they remain audible until coagulation takes place or the 
effusion is removed. When pulmonary apoplexy occurs, 



PULMONARY CANCER. 63 

it is usually found in the lower and posterior portions 
of' the lungs. If the nodules are few and small, there 
will be no positive physical evidences of their situation. 
When the nodules are large and lie superficially, percus- 
sion will give more or less dulness over a limited space 
corresponding to the extent of the haemorrhage, and on 
auscultation there will he a diminution or absence of the 
respiratory murmur. When the extravasation is situ- 
ated near a large-sized bronchial tube, bronchial breath- 
ing and increased vocal resonance are heard, and there 
is also increase in the vocal fremitus. 

Pulmonary Cancer. 

Cancer of the lungs may be primary or secondary. In 
the primary form, only one lung is affected, and the 
growth occurs as a single mass. In the secondary, both 
lungs are involved, and the new growth usually takes the 
form of disseminated nodules of varying size. The latter 
variety cannot be distinguished by physical examination 
from simple bronchial catarrh, but pulmonary symp- 
toms occurring a year or so after the removal of a can- 
cer are very suggestive. 

Where the growth is single and large- 

Inspection shows obliteration or bulging of the inter- 
costal spaces. This may, however, be due to a compli- 
cating liquid effusion. Occasionally there is retraction 
of the chest wall. The movements of respiration are 
impaired. 

Palpation gives diminished or absent vocal fremitus. 

Percussion gives comparative or absolute dulness, ac- 
cording as whether the mass is deep-seated or superficial. 

Auscultation. — The respiratory and voice sounds are 
usually absent over the affected portion of the lung. 
But if a large open bronchus passes through the mass. 



64 PHYSICAL DIAGNOSIS. 

bronchial breathing and voice will be heard. The signs 
on the healthy side may be exaggerated. 

Differential Diagnosis. — The only disease with which 
pulmonary cancer is likely to be confounded is pleurisy 
with effusion. In cancer, however, the line of dulness 
does not change when the position of the patient is 
altered; the dulness does not begin at the lowest portion 
of the thorax and extend upward ; and there may be 
one or more points where slight resonance on percus- 
sion is obtained. In cancer, the dulness is most marked 
in front, whereas in pleurisy it is greatest behind. Pain 
is present if the pleura is involved, and pressure symp- 
toms are sometimes seen. 

Pulmonary Collapse. 
Complete collapse of large portions of lung may be 
produced either by bronchitis or compression. There are 
no physical signs to indicate its occurrence, unless the 
collapsed lung is in contact with the chest wall, and then 
the signs are not very distinctive. Usually there is over 
the space where it occurs some dulness on percussion, 
localized bronchial breathing, and increased vocal fremi- 
tus. When there is collapse of only a few vesicles, a 
deep inspiration may bring out a crepitant rale, audible 
during a few respirations, and then heard no more. 
Congenital atelectasis gives rise to no physical signs, 
unless there is marked inspiratory dyspnoea and retrac- 
tion of chest walls. 

Pulmonary Congestion. 

There are no recognizable physical signs of simple 
pulmonary congestion, unless it is associated with pul- 
monary oedema or bronchial haemorrhage. 

It may be suspected when extreme dyspnoea comes on 
suddenly after violent physical exertion, or daring the 



PULMONARY CONGESTION. 



65 



inhalation of highly rarefied air met with in high alti- 
tudes, especially if, with the dyspnoea, you have the 
physical signs of pulmonary oedema, and a watery blood- 
stained expectoration. 

Some auscultators have regarded intensification of the 
second sound of the heart over the pulmonary arteries as 
a diagnostic physical sign of pulmonary congestion ; but 
tnis evidence is fallacious, for greater intensity of the 
second pulmonary sound may be merely relative, and due 
to weakness of the aortic sound. 
5 



LESSOR VIII. 

A SYNOPSIS OF PHYSICAL SIGNS IX THE DIAGNOSIS OF 
PULMONARY DISEASES — CONTINUED . 

Pleurisy. 

There are three recognized varieties of pleurisy, Acute, 
Sub- Acute, and Chronic or Empyema. In acute, there is 
but little liquid effusion ; in sub -acute, the liquid effusion 
is abundant, often completely filling the pleural cavity; 
in empyema, the effusion is purulent, comparatively 
small in quantity, and usually circumscribed. I shall 
consider the physical signs of the three varieties sepa- 
rately. 

Acute Pleurisy 

may be divided into four stages — a dry stage, a plastic 
stage, a stage of liquid effusion, and a stage of absorp- 
tion. 

Dry Stage. — Inspection shows a diminution in the 
respiratory movements, especially in expansion of the 
affected side. They are also quick, catching, and irreg- 
ular. Palpation, mensuration, and percussion yield only 
negative results. 

Auscultation. — The respiratory murmur is feeble, 
jerking, and interrupted ; occasionally a grazing friction 
sound is heard over the seat of the pleuritic inflamma- 
tion. 

Stage of Plastic Exudation. Inspection. — The res- 
piratory movements of the affected side are still more 



ACUTE PLEURISY. 07 

diminished, while those of the healthy side are in- 
creased. 

Palpation. — Vocal fremitus is diminished. 

Percussion. — There is more or less dulness over the 
seat of the plastic exudation. If the dulness is marked, 
the plastic matter is abundant. The dulness will be less 
at the end of a full expiration. 

Auscultation. — The respiratory murmur over the seat 
of the pleuritic inflammation is feeble or entirely absent, 
and a rubbing or crepitating friction sound is heard, 
most distinctly at the end of the inspiratory act, as 
shown in Fig. 5, p. 45. 

Vocal Resonance. — The intensity of the vocal re- 
sonance is diminished. 

Stage of Liquid Effusion. Inspection. — In acute 
pleurisy the quantity of liquid effusion is generally 
small, as shown in Fig. 5 ; consequently there is no 
dilatation of the affected side. When it appears, the 
jerking movements of the dry and plastic stages cease, 
and there is no visible motion at the seat of the liquid 
accumulation. 

Palpation. — Vocal fremitus is absolutely suppressed 
over the effused liquid. 

Percussion. — When the patient is sitting or standing, 
there is flatness on percussion, from the base of the lung 
on the affected side to the level of the liquid, as shown in 
Fig. 5. The line of the flatness may be changed by 
changing the position of the patient. 

Auscultation. — The respiratory sounds below the 
level of the liquid are diminished or suppressed ; above, 
they are exaggerated. The friction sounds disappear 
where the effusion prevents the pleural surfaces from 
coming in contact with each other; but above the liquid 
they continue to be heard, as shown in Fig. 5. 



68 PHYSICAL DIAGNOSIS. 

Vocal Resonance. — Below the level of the liquid the 
vocal sounds are feeble or entirely abolished. 

Stage of Absorption. — This stage is marked by the 
gradual return of pulmonary resonance on percussion, 
and of the normal vocal and respiratory sounds. As the 
effusion disappears creaking friction sounds are audible 
for a brief period. 

Sub-Acute Pleurisy. 
In this variety of pleurisy the pleural cavity may be 
partly or completely filled with liquid. In addition, there 



Absence of respiratory sounds 
" " vocal sounds. 

" ' ; vocal fremitus. 



Flatness on percussion 




Flo. 7.— Diagram showing the Pleural Cavity completely filled with Liquid, the Lunjr 
being compressed. 

is a moderate amount of plastic exudation, which thick- 
ens and roughens the pleural surfaces. When the cavity 
is partly filled, the presence and amount of the effusion 
are determined by the same physical signs that mark the 
effusive stage of acute pleurisy. When the pleural 
cavity is distended by accumulation of the liquid, the 
lung is compressed against the spinal column, and impor- 
tant changes in the physical signs occur. 



SUB-ACUTE PLEURISY. 69 

Inspection shows perfect immobility of the chest walls, 
with general enlargement of the affected side. The inter- 
costal spaces bulge more or less, and the cardiac impulse 
is visible in an abnormal position. 

Mensuration shows an enlargement of the affected 
side, both in its circumference and in its antero-posterior 
diameter ; the enlargement is greatest over the false 
ribs, the affected side often measuring one or two inches 
more than the healthy. 

Palpation shows the vocal fremitus to be wanting. 

Percussion. — There is general flatness on percussion 
over the affected side, the flatness extending beyond the 
natural limits of the lung. Under the clavicle the per- 
cussion sound sometimes has a tympanitic quality. 

Auscultation. — There is entire absence of all respira- 
tory and vocal sounds over the affected side, except at 
the upper portion of the compressed lung ; here bron- 
chial respiration and bronchophony are heard. Some- 
times these sounds are diffused over the affected side. 
The respiratory sound over the healthy lung is exag- 
gerated. 

In the Stage of Absorption, inspection informs us 
that the enlargement of the affected side is disappear- 
ing, that the intercostal spaces are regaining their normal 
condition, and that the respiratory movements of the 
chest walls are returning, although restricted. 

Palpation shows a gradual return of vocal fremitus. 

Mensuration shows a gradual diminution in the mea- 
surement of the affected side, until it becomes even less 
than the opposite side. 

Percussion. — The percussion sound gradually recovers 
its normal resonance, first at the upper and then at the 
lower portion of the pleural cavity; sometimes in the 
inferior portion it never regains its normal resonance, 



70 PHYSICAL DIAGNOSIS. 

owing to the great accumulation of solid, plastic mate- 
rial, or condensation of lung tissue. 

Auscultation. — The respiratory sounds are again 
heard, at first weak and distant; gradually they become 
more distinct, and sometimes harsh in character. As 
the absorption of the liquid takes place, and the two 
surfaces of the pleura again come in contact, a friction 
sound, of a creaking, crepitating character, appears, and 
remains audible for a variable period. The vocal reso- 
nance is at first bronchophonic, then exaggerated, and 
ultimately becomes normal. The heart, with the ad- 
jacent aMominal viscera, returns to its normal position, 
sometimes with singular promptness. If, as sometimes 
happens, the lung remains permanently impervious to 
air, then there is a permanent loss of motion on the 
affected side, and there is no return of the respiratory or 
vocal sounds, while dulness on percussion is persistent. 
A portion of the lung (usually the upper) sometimes 
becomes partially pervious to air ; when this is the 
case, the percussion sound over it will have a tympa- 
nitic quality, the vocal resonance will be exaggerated, 
and the respiratory sound coarse and blowing. 

Empyema. — The physical signs of empyema are the 
same as those of sub-acute pleurisy, when the pleural 
cavity is partially filled with liquid. In the majority of 
the cases of empyema that have come under my obser- 
vation, a change in the position of the patient has not 
caused a change in the level of the liquid, owing prob- 
ably to the firm adhesion that takes place above it be- 
tween the pleura pulmonalis and pleura costalis. Ex- 
cessively abundant empyematous effusions sometimes 
pulsate rhythmically with the heart — the "pulsating 
empyemata. " 

Differential Diagnosis. — The diagnosis of pleurisy, 



SUB-ACUTE PLEURISY. 71 

in the majority of cases, is easily made ; yet in all its 
different varieties there is some danger of confounding 
it with other diseases. 

In the dry stage of acute pleurisy it may be con- 
founded with pleurodynia and intercostal neuralgia. It 
is distinguished from them by the presence of the graz- 
ing friction sound, by the deep-seated character of the 
pain, and by the absence of tenderness on pressure over 
the seat of pain. It is further differentiated from inter- 
costal neuralgia by not having the three points of ten- 
derness, viz. : at the exit of the nerve from the spinal 
canal, over the greatest curvature of the rib, and in front. 

The plastic stage of pleurisy on the left side may 
be confounded occasionally with the plastic stage of 
pericarditis. It is readily distinguished from it by the 
cessation of the friction sound during a temporary sus- 
pension of the respiratory movements. 

The effusive stage may be confounded with con- 
solidation of the lung from pneumonia and tubercular 
infiltration, with an enlarged liver or spleen extending 
upward, and with cancerous deposits in the lungs. It 
is distinguished from pneumonia and tubercular consoli- 
dation by the bulging of the affected side, by the ab- 
sence of vocal fremitus, by the flatness of the percussion 
sound, by the change in the level of the liquid on change 
in the position of the patient, and by the absence of all 
vocal and respiratory sounds. The blowing respiration 
that is sometimes heard over a pleural cavity filled with 
liquid differs from the true tubular or bronchial breath- 
ing of pulmonary consolidation in being more diffused 
and deep-seated, and not accompanied by any moist 
sounds. In tubercular consolidation, the progress of the 
physical signs is usually from above downward ; in ef- 
fusion, they advance from below upward. Besides, 



72 PHYSICAL DIAGNOSIS. 

pulmonary tuberculosis of an entire lung does not exist 
without involving the opposite lung, while any amount 
of pleuritic effusion may exist on one side while the 
other remains unaffected. 

The physical signs of the stage of absorption will 
rarely be confounded with any other disease. Hyper- 
trophy of the liver, enlarging upward, is distinguished 
from effusion into the right pleural cavity by the exist- 
ence of pulmonary percussion and audible respiratory 
murmur at the posterior part of the chest. Deep in- 
spiration also increases the area of the normal percus- 
sion and normal respiratory sound at the inferior por- 
tion of the pleural cavity ; it exerts no such influence 
when the loss of resonance and respiratory murmur de- 
pends upon pleuritic effusion. 

Enlargement of the spleen affects but slightly the vo- 
cal or respiratory sounds at the inferior portion of the 
left pleural cavity. It causes no protrusion of the inter- 
costal spaces, and does not, like pleuritic effusion, push 
the heart to the right, but raises it upward. 

Pneumothorax. — Inspection shows distention of the 
affected side, widening and bulging of the intercostal 
spaces, and immobility of the chest walls, contrasting 
forcibly with the costal movements of the healthy side. 

Palpation. — Vocal fremitus is diminished, or alto- 
gether wanting. Mensuration shows the affected side 
to be markedly increased in size. 

Percussion elicits a tympanitic resonance, of an am- 
phoric or metallic quality, over the whole of the affected 
side. When the dilatation of the chest is excessive, the 
adjacent viscera are more or less displaced. The tym- 
panitic percussion sound assumes a muffled character, 
and extends considerably beyond the normal limits of 
the pleura. 



PNEUMOTHORAX. 



73 



Auscultation varies according to the amount of air 
contained in the pleural cavity. If the cavity is dis- 
tended with air, so that the lung is completely com- 
pressed, the vocal and respiratory sounds are altogether 
absent, and the heart sounds are feebly transmitted 
through the distended pleura ; if the quantity of air is 
small, the respiratory sounds are weak and distant, and 
the vocal sounds indistinct. 

Hydro-pneumothorax usually results from the open- 



Tympanitic resonance. . 
Amphoric respiration. . 
Metallic tinkling. . . . 
Succussion sound. . . . 
Absent vocal fremitus. . 

Flatness 

Absent voice 

Absent respiration. . . 
Displaced viscera. . . . 




Fig. 8.— Diagram illustrative of the Physical Signs of Hydro-pneumothorax. 



ing of a bronchus into the pleural cavity. The physical 
signs of this condition are a combination of those of 
pleuritic effusion and pneumothorax. As in pneumo- 
thorax, inspection reveals dilatation of the affected side, 
widening and bulging of the intercostal spaces, immo- 
bility of the chest walls, and displacement of the heart 
and adjacent viscera. There is entire absence of vocal 
fremitus. 

Percussion. — When the patient is sitting or standing, 
there will be tympanitic resonance on percussion from 



74 PHYSICAL DIAGNOSIS. 

the summit of the affected side to the level of the liquid, 
and flatness below ; the relation of the flatness and tym- 
panitic resonance changing with the change in the posi- 
tion of the patient. 

Auscultation. — Below the level of the liquid there is 
entire absence of all the respiratory and vocal sounds ; 
above its level there is usually amphoric respiration and 
metallic tinkling. 

The characteristic physical sign of this disease is the 
succussion sound, which is a metallic, splashing sound, 
produced by abruptly shaking the chest while the ear is 
resting on its surface. 

The respiration on the healthy side is exaggerated. 
When pneumothorax is secondary to advanced tuber- 
culosis, the lung often remains adherent to the chest 
wall, and great distention of the affected side is pre- 
vented. Complete catarrhal obstructions in the main 
bronchi sometimes give signs similar to those of pneu- 
mothorax. 

Pulmonary Tuberculosis. 

Tuberculosis of the lungs may be divided into Acute 
and Chronic. The Acute occurs in two forms, Acute 
Miliary Tuberculosis and Acute Tubercular Pneumonia. 

ACUTE MILIARY TUBERCULOSIS. 

Acute Miliary Tuberculosis, in which there is a dis- 
semination of miliary tubercles throughout the lungs, 
cannot be differentiated, by the physical signs, from a 
catarrh of the smaller bronchial tubes. The diagnosis 
rests upon an examination of the sputum (see page 207), 
but is only of value when a positive result is obtained. * 

1 Yon Jaksch states that the bacilli are never present in this form 
of the disease. 



CHRONIC PULMONARY TUBERCULOSIS. 75 

ACUTE TUBERCULAR PNEUMONIA. 

In this form of the disease, lobules or an entire lobe 
may rapidly become consolidated. The physical signs 
are the same as those of lobular or lobar pneumonia (see 
pages 58 and 60). Here again the microscope is neces- 
sary to complete the diagnosis. 

CHRONIC PULMONARY TUBERCULOSIS. (Chronic PhtJltSlS.) 

Early Stage. — The lesion is usually situated about 
an inch from the apex of the lung, and nearer the pos- 
terior than the anterior surface ; consequently the physi- 
cal signs will be best marked behind. 

Inspection affords little information unless the con- 
solidation is extensive and confined to one apex, where 
expansion in the infra- and supra-clavicular regions of 
the affected side will be diminished, and there will 
be some flattening of the upper part of the chest 
wall. 

Palpation. — By palpation you will often detect de- 
ficient expansion in the infra-clavicular region of the 
affected side when it cannot be detected by inspection. 
There is also slight increase in the vocal fremitus ; this 
increase, however, is less significant when it occurs on 
the right side than on the left. 

Percussion. — The difference in the percussion note in 
the infra-clavicular region on the two sides, rather than 
the quality of the sound, is important. But it must be 
remembered that normally there exists a discrepancy in 
the two sides. On the right the pulmonary resonance is 
less marked and the pitch of the percussion sound is 
aigher. 

If the consolidation is slight and superficial, the pitch 
tf the percussion sound on the affected side will be 



76 PHYSICAL DIAGNOSIS. 

slightly raised. But if healthy or emphysematous lung 
tissue intervene between the consolidated lung and the 
chest walls, the percussion sound may be normal, or ex- 
tra resonant, over the affected portion. To detect pul- 
monary consolidation under such circumstances, the per- 
cussion blow must be forcible, and directed from, not 
toward, the trachea. If doubts exist, the percussion 
should be performed at the end of a full inspiration and 
at the end of a full expiration. As consolidation in- 
creases, the pitch of the percussion sound rises and its 
clearness diminishes, until, in some cases, absolute dul- 
ness is reached. 

Auscultation. — The respiratory sound in the infra - 
and supra-clavicular regions of the affected side is weak 
or suppressed at some points, and exaggerated at others. 
It may be jerking, wavy, or " cogged- wheel" in its 
rhythm, and rude or bronchial in its quality. The in- 
spiratory sound loses its soft, breezy character, and be- 
comes higher pitched and tubular ; while the expiratory 
becomes higher pitched than the inspiratory, and is pro- 
longed. Prolonged expiration, however, if unattended 
with any alteration in quality, is insignificant. The 
value of these states of the respiration corresponds to 
their position. If they exist above and are imperceptible 
below the second interspace, they are seriously signifi- 
cant. Localized mucous or sub-crepitant rales, heard 
over a limited space at the apex of the lung, are always 
important signs of tuberculosis, and indicate the de- 
velopment of broncho- or catarrhal pneumonia. They 
are often present before any appreciable change in the 
respiratory murmur occurs. At first they are more or 
less obscure in proportion to the weakening of the res- 
piration ; gradually they become more distinct and nu- 
merous as the pulmonary consolidation increases. The 



CHRONIC PULMONARY TUBERCULOSIS. 7? 

heart sounds over the affected lung will be increased in 
intensity. 

Vocal resonance is subject to so many variations as to 
render it almost valueless as a means of diagnosis. Ex- 
aggerated vocal resonance at the left apex is of some im- 
portance. 

The Advanced Stage is marked by a greater involve- 
ment of lung tissue. The consolidation extends, and is 
attended by softening, and the formation of cavities. 
There is a diminution in the volume of the lung, with 
corresponding contraction of the chest walls. 

The diagnosis of a cavity demands that it be near the 
surface, not smaller than a walnut, and for the most 
part contain air. 

Inspection. — The respiratory acts are much increased 
in frequency, and marked depression will be noticed 
above and below the clavicles. There is deficiency in 
local expansion, especially during a full inspiration ; or 
it may be that the respiratory movements are arrested 
in the supra- and infra-clavicular regions. 

Palpation. — The vocal fremitus, as a rule, is in- 
creased over the consolidated area, and over a large 
superficial cavity when partially or completely filled. 
Sometimes a gurgling fremitus may be detected. 

Percussion. — Before cavities are formed there is a 
widespread and more intense dulness than in the Early 
Stage. It often assumes a wooden or a tubular charac- 
ter. After the formation of cavities the percussion 
sound varies according to the condition of the cavi- 
ties themselves and the lung tissue surrounding them. 
If the cavity is of small size and surrounded with con- 
solidated lung tissue, the percussion sound will be ab- 
solutely dull or tubular in quality ; if a layer of healthy 
lung tissue intervene between the chest walls and the 






78 PHYSICAL DIAGNOSIS. 

cavity, the latter being full, gentle percussion will give 
normal resonance, while forcible percussion will elicit 
deep-seated dulness. Large, empty, superficial cavities 
with thin, tense walls yield an amphoric or " cracked- 
pot " resonance. 

Auscultation. — Over consolidated areas the respira- 
tion grows more intensely bronchial, and moist, crack- 
ling rales of a metallic character are heard. The rales 
sometimes are sticky in character, and do not change or 
disappear on coughing. 

If a cavity is empty and communicates freely with a 
bronchial tube, and no healthy lung tissue lies between 
it and the chest walls, the respiration will be either cav- 
ernous or amphoric (as shown in Fig. 4, page 4A)— cav- 
ernous, when the cavity is of small size, with a flaccid 
wall that collapses with expiration and expands with in- 
spiration ; amphoric, when the cavity is large and sur- 
rounded with consolidated lung, or with a thick, fibrous 
wall that does not collapse in expiration. If liquid has 
accumulated in the cavity in sufficient quantity to rise 
above the opening into it, large or small- sized gurgles 
will be heard (as shown in Fig. 4, page 44). Metallic 
tinkling will sometimes be heard over cavities of large 
size. Vocal resonance may be amphoric, bronchophonic, 
weak, or entirely absent ; pectoriloquy may be present. 
Small cavities partially filled with liquid, and deeply 
seated, do not give rise to the signs characteristic of cavi- 
ties, but simply furnish blowing respiration and small- 
sized gurgles, which resemble very closely mucous rales. 

A cavity may be presumed to exist at the point where 
the bronchial breathing is most intense and the moist 
sounds are most metallic in quality. The difficulty with 
which tuberculosis is differentiated from some forms of 
pleurisy and pneumonia has already been indicated. 



HEART 



AND 



THORACIC AORTA. 



LESSOR IX. 

TOPOGRAPHY OF THE HEART AND AORTA — PHYSIOLOGICAL 
ACTION OF THE HEART. 

The diagnosis of many cardiac diseases rests npon our 
knowledge of the relations of the different compart- 
ments and orifices of the heart to the chest walls. It is. 
therefore necessary to be familiar with this relationship, 
and with the physiological acts which constitute a com- 
plete cardiac cycle, before we can study intelligently 
the physical signs involved in the diagnosis of these 
diseases. 

By referring to Fig. 1, page 5, the relations of the 
heart to the adjacent viscera will be readily appreciated. 

In the healthy chest, the auricles are on a line with 
the third costal cartilages. The right auricle extends 
across the sternum, a little beyond its right border. 
The left auricle lies deeply behind the pulmonary artery. 
The middle portion of this auricle corresponds to the 
cartilage of the third rib. The tip of the auricular ap- 
pendix appears anteriorly to the left of the root of the 
pulmonary artery. The right ventricle lies partly be- 
hind the sternum, and partly to the left of it; its in- 
ferior border is on a level with the sixth cartilage. The 
left ventricle lies for the most part to the left of the ster- 
num, between the third and fifth intercostal spaces- 
Only a narrow strip of the ventricle is visible anteriorly.. 
The heart, then, as a whole, extends vertically from the 
second space to the sixth costal cartilage, and transverse- 
ly from about half an inch to the right of the sternum 
to within an inch of the left nipple line. Posteriorly, 
6 



r 



82 PHYSICAL DIAGNOSIS. 

the base lies opposite the sixth and seventh dorsal ver- 
tebras. The left ventricle, the greater part of the left 
auricle, and a large portion of the apex of the right ven- 
tricle, lie to the left of the sternum. Behind the ster- 
num lie a greater portion of the right auricle and ven- 
tricle, and a small portion of the left. To the right of 
the sternum lie a portion of the right auricle and the 
upper portion of the right ventricle. The whole of the 
anterior surface of the heart is overlapped by the lungs, 
except a triangular space corresponding to the lower 
portion of the right ventricle. 

The Surface Measurements of the heart are as fol- 
lows : Vertical measurement from the second interspace 
to the fifth interspace, five inches ; from the median 
line to the left, on the third rib, two and a half to three 
inches ; on the fourth rib, from three and a half to foui 
inches ; in the fifth interspace, from three to three and 
a half inches. 

Relative Position of the Valves. 

The Tricuspid Valve lies behind the middle of the 
sternum, at the level of the fourth costal cartilage. 

The Mitral Valve lies behind the third intercostal 
space, about one inch from the sternum. It is the 
deepest of all. 

The Aortic Valves lie behind the sternum, near its 
left edge, a little below the junction of the third costal 
cartilage. 

The Pulmonary Valves lie behind the junction of 
the third left costal cartilage with the sternum. A circle 
of an inch in diameter with its centre at the left edge of 
the sternum, a little below the junction of the third rib 
with the sternum, will include a portion of all these four 
sets of valves. 



PHYSIOLOGICAL ACTION OF THE HEART. 83 

The Aorta arises from the left ventricle behind the 
sternum, opposite the third intercostal space, and passes 
from left to right. The ascending portion of the arch 
comes to the right of the sternum between the cartilages 
of the second and third ribs. In this part of its course 
it is within the pericardial sac. Thence the transverse 
portion of the arch crosses the trachea just above its bi- 
furcation (at the centre of the first bone of the ster- 
num), and, passing backward and downward toward 
the left side of the third dorsal vertebra, becomes the de- 
scending portion. It rests ultimately upon the left side 
of the bodies of the fifth and sixth dorsal vertebrae. 
The arch of the aorta approaches most closely to the 
chest walls at the point where the arteria innominata is 
given off — that is, on a line with the junction of the car- 
tilage of the second right rib with the sternum. 

The Pulmonary Artery arises from the right ven- 
tricle, to the left and behind the sternum, on a line with 
the junction of the cartilages of the third ribs with the 
sternum. It passes upward and backward about two 
inches, when it bifurcates opposite the second costal car- 
tilage. 

The Pericardial Sac encloses the heart, and may be 
represented as a cone, extending from the second to the 
seventh left costal cartilage. The base of the cone rests 
on, and is attached to, the diaphragm, and the apex em- 
braces the lower two inches of the great vessels. The 
larger portion of the sac lies to the left of the median 
line, and is further from the anterior chest wall su- 
periorly than it is inf eriorly. 

Physiological Action of the Heart. 
A contraction of the heart begins in the great veins 
and proceeds as a peristaltic wave to the auricles. They 



84 



PHYSICAL DIAGNOSIS. 



rapidly contract, and are immediately followed by the 
ventricular contraction, or systole. After a contraction 
the muscular tissue relaxes, and a period of rest ensues, 
the diastole. A complete cardiac cycle consists of the 
contraction and dilatation of each of the cavities of 
the heart. During the ventricular systole there is a 
change in its form, size, and position. 

Auricular Diastole.— The blood is pouring from 
the great veins into the auricles, and through the auri- 
culo-ventricular openings into the ventricles below. 




Fig. 9.— Diagrammatic representation of the Changes that occur in the Valves and 
Cavities of One Side of the Heart during a Cardiac Cycle. 






The semilunar valves are closed, as seen in Fig. 9. 
When the auricles become distended the 

Auricular Systole begins. As it progresses they 
become smaller, and their walls crowd toward the 
opening into the ventricles below, forcing a small quan- 
tity of blood before them. The semilunar valves still 
remain closed. 

Ventricular Systole. — The contraction of the au- 
ricles completely fills the ventricles with blood. At the 
same time, it is supposed, the flaps of the mitral and tri- 
cuspid valves are floated into place by reflex currents. 



PHYSIOLOGICAL ACTION OF THE HEART. 85 

along the sides of the cavities. Everything is now 
ready for contraction. Suddenly the ventricular walls 
become tense and hard, the shape of the heart becomes 
more distinctly conical, and it rotates on its long axis 
from left to right, bringing more of the left ventricle to 
the front. The systole is complete. The blood has been 
forced into the aorta and pulmonary arteries respec- 
tively. During its passage the cusps of the semilunar 
valves have been pressed toward, but not against, the 
arterial walls. Any reflux of blood into the auricles, or 
even bulging of the auriculo-ventricular valves, is pre- 
vented by the contraction of the muscular papillae. 
They draw upon the chordae tendineae, and hold the flaps 
in close apposition. The cardiac impulse is synchronous 
with the ventricular systole, and is caused by the impact 
of the rigid heart against the chest wall. It is most dis- 
tinctly felt in the fifth intercostal space, just to the me- 
dian side of the mammillary line. The first sound of 
the heart is heard with the ventricular contraction, and 
is of a loud, " booming" character. It is probably of 
combined muscular and valvular origin. 

Ventricular Diastole. — After a short interval the 
second sound is heard. It is sharp and sudden in cha- 
racter, and is caused by the closure of the semilunar 
valves. At its occurrence the ventricles have just fin- 
ished their systole and are beginning to relax. Then 
succeeds the diastole. The ventricular walls become 
flaccid, the heart returns to its former position, the 
valves at the mitral and tricuspid orifices open, and the 
blood flows in from the auricles, preparatory to the com- 
mencement of another cycle. The semilunar valves are 
closed by the negative pressure produced at the end of 
the systole, or by the elastic recoil of the over-distended 
arteries. 



86 



PHYSICAL DIAGNOSIS. 



Duration of the Different Phases.— The ventricu- 
lar systole occupies about three-eighths of an entire 
cardiac cycle; the auricular systole, about one-eighth ; 
and the diastole of the auricles and ventricles, about 
one-half. 

But it must be remembered that the ventricles are at 
rest also during the auricular systole ; so it will be seen 
that they work less than one-half the time. 

Fig. 10 well illustrates the sequence of events in a 




Fig. 10.— Representation of the Movements and Sounds of the Heart during a Car- 
diac Cycle —Dr. Sharpey. 

cardiac cycle. It is not intended that its measurements 
shall be exact. 

The normal pulse rate of the heart is 12 to the minute, 
though it varies considerably in different individuals, 
and in the same individual at different times. Thus, it 
is more rapid in women and children than in men, and 
it becomes accelerated after a full meal. A rapidly beat- 
ing heart differs from a slowly beating heart chiefly in 
the length of its diastole. As the length of the diastole 
increases, the greater becomes the interval between the 
second and first sounds of the heart. Fig. 11 is a series 
of circles representing the altered relations of the sounds 



DURATION OF THE DIFFERENT PHASES. 



87 



in slowed or accelerated heart action. The first and 
second sounds correspond, respectively, to radii 1 and 2. 
The larger circumference of each successive circle in- 
dicates the lengthening of the pause. The interval be- 
tween the first and second sounds becomes relatively 
shortened as the heart's action is slowed, and is repre- 
sented by a smaller arc; while the 
interval between the second and first 
sounds is lengthened. In the first 
and smallest circle, indicating the 
most rapid action, the two intervals 
are nearly equal, and each occupies 
about one-half the circumference ; in 
the last or largest circle the interval 
between the second and first sounds 
is about four times as long as that 
between the first and second. Hence 
it is that, when the heart is acting 
rapidly, it is difficult to distinguish 
the first sound from the second, and 
vice versa; while with the slowly 
acting heart this difficulty does not 
occur. Attention to these varieties 
— physiological varieties they may 
be called — in the rhythm of the 
sounds is of very great importance in determining the 
attributes of a cardiac murmur, for the first step in 
the inquiry is to determine which is the second sound 
and which is the first. This, as I have said, is sometimes 
not an easy matter. Generally speaking, and in all cases 
when the action is slow and regular, there is no diffi- 
culty. You have only to remember that the longer 
interval is between the second and first sounds, and the 
shorter interval between the first and second. But when 




Fig. 11. 



88 PHYSICAL DIAGNOSIS. 

the action is rapid or irregular, and when the first sound 
is indistinct at the apex, or cannot be identified with the 
apex beat, and also when the second sound is indistinct, 
or when it is audible only at the base, the first sound 
being audible only at the apex, as sometimes happens, 
the difficulty of recognition of the two sounds is very 
considerable. 



LESSOR X. 

METHODS OF CARDIAC PHYSICAL EXAMINATION. 

The methods of physical examination of the heart in- 
clude inspection, palpation, mensuration, percussion, 
and auscultation. 

By Inspection you note the exact point of the heart's 
impulse against the chest wall, whether there is any un- 
usual pulsation, or any change in the form of the cardiac 
region. In a perfectly normal chest, the infra-mam- 
mary regions on either side are very nearly symmetrical ; 
but in disease the precordial region may be depressed, 
or arched forward, and the intercostal spaces may be 
widened. The most important information furnished 
by inspection relates to the cardiac impulse. This, in 
the majority of persons, is visible only in the fifth inter- 
space, midway between the left nipple and the sternum, 
and its area does not exceed a square inch. You will 
find it most distinct in thin persons, while in fleshy per- 
sons it is sometimes not discernible. You will find also 
that it may be displaced by a change of position, by dis- 
tention of the subjacent stomach, and by the movements 
of respiration. Thus, during a full inspiration you may 
see the impulse lowered an intercostal space, and then 
during a forced expiration see it elevated and more 
diffused. 

Change in the situation of the impulse may result 
from disease of the heart itself, disease of the pericar- 
dium or of the adjacent viscera. In cardiac hyper- 



90 PHYSICAL DIAGNOSIS. 

trophy it is displaced downward and to the left, while 
in pericardial effusion it is displaced upward. It may 
be carried upward and to the left by enlargement of the 
left lobe of the liver, or downward and to the right 
by simple pleuritic effusion or emphysema. I have seen 
the impulse even external to the right nipple. Not in- 
frequently in cases of pericardial agglutination, or dila- 
tation of the ventricles, an undulating impulse will be 
visible. 

When from any cause the impulse cannot be seen, its 
position must be determined by palpation. 

Palpation. — This is of much greater clinical impor- 
tance than inspection. By it we determine the force of 
the cardiac pulsation, the frequency or slowness of the 
heart's action, and the regularity or irregularity of its 
movements. By it, also, we detect the presence of the 
friction fremitus, and what is termed the "purring 
thrill." 

The force of the cardiac impulse may be diminished or 
increased. 

Diminution in the force of the impulse may be due to 
degeneration of the heart wall, or to prostration of the 
whole system, as in collapse. It is also diminished when 
the apex is prevented from impinging against the wall 
of the chest with its customary force, as happens in dis- 
ease of the lungs or pericardium. 

Increase in the force of the impulse. — In the ma- 
jority of instances, this is caused by hypertrophy of the 
walls of the left ventricle. A slow, progressive impulse 
can be produced by no other cause. In such cases, 
the area over which the cardiac impulse can be felt is 
much increased. In the early stage of endocarditis and 
pericarditis, and in palpitations from functional disor- 
ders, the impulse is slightly increased. 



PERCUSSION. 91 

The frequency and regularity of the heart's action is 
of great importance in the diagnosis of cardiac disease. 
It can often be most accurately determined by palpation. 

The Purring Thrill (the ' ' fremissement cataire" of 
Laennec) is a peculiar vibratory sensation perceptible on 
making pressure at the precordium. In some the pres- 
sure need be but slight, while in others it should be firm. 
It may also be communicated by the large arteries, etc. 
• Percussion. — By percussion we aim to determine the 
exact outline of the heart and of its investing membrane, 
to see whether it exceeds its normal area. In perform- 
ing cardiac percussion you will find both care and pa- 
tience necessary to obtain accurate results. The patient 
should be in a recumbent posture. You need tap but 
lightly over the part where the heart is not covered by 
lung tissue, to obtain a flat sound ; but where the lungs 
overlap the organ, you must percuss more forcibly to 
elicit cardiac dulness, and this sound will of necessity 
have more or less of a pulmonary quality. We have, 
therefore, two degrees of cardiac dulness — the super- 
ficial and the deep-seated. In health the area of the 
superficial dulness does not exceed two inches in any di- 
rection. It is triangular in form, with the apex imme- 
diately below the junction of the left third rib with the 
sternum, while the base is on a line with the cartilage of 
the sixth rib. The area of the deep-seated dulness in 
health extends transversely from the left nipple to half 
an inch to the right of the sternum, and vertically from 
the second to the sixth interspace. 

The area of the heart's superficial dulness may be in- 
creased or diminished : increased, when the ventricles 
are hypertrophied, or when their cavities are dilated, 
and also when the pericardium contains liquid ; dimin- 
ished, at the end of a full inspiration, and in pulmonary 



92 PHYSICAL DIAGNOSIS. 

emphysema where there is a general distention of the 
air cells, causing the lingula of the left lung to cover 
the otherwise exposed portion of the heart. The area of 
the deep-seated dulness is increased by enlargement of 
the heart, whether this be due to ventricular dilatation 
or to hypertrophy of its walls. It is apparently in- 
creased by consolidation of the anterior border of the 
investing lung, and by liquid in the left pleural cavity. 
We are often, in certain cases, much assisted in deter- 
mining the limits of the deep-seated dulness by auscul- 
tatory percussion. 

Auscultation. — For reasons already stated I prefer 
mediate to immediate auscultation in examining the 
heart, and in practising it you will find the following 
simple rules of service : 

1. The posture of the patient should be recumbent 
when you begin your examination. Then, having care- 
fully elicited all the auscultatory signs which this pos- 
ture affords, repeat your examination with him sitting 
or standing, and note whether any variations in the 
sounds heard have occurred from the change in his 
position. 

2. You should first listen to the heart sounds while 
the patient is breathing naturally ; having done so, then 
direct him to hold his breath for a moment ; and finally 
tell him to take three or four forced inspirations. All of 
these means are often requisite before we can correctly 
discriminate between the different signs of cardiac aus- 
cultation. 

3. You should not confine your examination to the 
precordial region alone, but should explore the whole 
thoracic cavity, and endeavor to localize the points at 
which the heart sounds, both normal and abnormal, are 
heard with the greatest intensity. To this end proceed 



INTENSITY OF HEART SOUNDS. 93 

in your examination from below upward, and from 
left to right. 

As in the case of pulmonary auscultation, so here, the 
normal characters must be the starting-point or standard 
to which every sound in cardiac auscultation is to be 
compared. You cannot, therefore, pay too much atten- 
tion to acquiring a familiarity with the elements of the 
heart sounds in health. These elements are as follows : 
When the ear or stethoscope is applied to the precordial 
region, two successive sounds are heard, followed by an 
interval of silence. The first sound is softer, lower in 
pitch, and more prolonged than the second ; as has al- 
ready been shown in Fig. 10, it coincides with the sys- 
tole of the ventricles and with the apex beat. It imme- 
diately precedes the radial pulse, and has its maximum 
of intensity in the fifth interspace, a little to the right of 
the left nipple line. The second sound is sharper, or 
higher pitched, shorter and more superficial than the 
first. It marks the beginning of the ventricular dias- 
tole, occurs after the pulsation of the arteries, and has 
its maximum of intensity at the junction of the third 
left rib with the sternum. 

The period of silence immediately following the sec- 
ond sound varies in length with the rapidity of the 
heart's action. The order and duration of the sounds, 
and the silence, you will be able to appreciate best by re- 
ferring to diagrams Nos. 10 and 11 (pages 86 and 87). 

The intensity of the heart sounds varies in health ac- 
cording to the force of the heart's action, or according 
to the conformation of the chest, or according to indi- 
vidual idiosyncrasies. These sounds are less intense in 
fleshy or muscular persons with capacious chests than 
in thin, narrow-chested, and nervous individuals. 

The extent of surface over which the heart sounds are 



94 PHYSICAL DIAGNOSIS. 

heard varies with the adaptation of the adjacent organs 
for transmitting sounds. Generally speaking, the sounds 
produced on the right side of the heart are more audible 
on the right side of the precordial region, while those 
produced on the left are more pronounced on the cor- 
responding side. 

Pathological Modifications of the Normal 
Sounds. — In disease the normal sounds of the heart 
present various alterations as regards their intensity, 
quality, pitch, seat, and rhythm. They may also be 
accompanied, preceded, or followed by adventitious 
sounds or murmurs. 

An increase of intensity may be noted in cases of 
hypertrophy and dilatation of the ventricles, in cases of 
nervous irritability of the heart, or where there is con- 
solidation of the adjacent lung tissue. A diminution 
in intensity may be found depending either upon dilata- 
tion of the ventricles without hypertrophy of their 
walls ; upon fatty degeneration of the muscular tissue 
of the heart ; upon the granular or hyaline changes 
occurring in infectious fevers ; or it may be owing to 
a muffling of the heart sounds by pericardial effusion, 
or by emphysematous distention of the anterior border 
of the lung. 

Alterations in Quality and Pitch. — The heart sounds 
in disease may become dull and low-pitched, or sharp 
and high-pitched. The first sound is dull, muffled, and 
low-pitched when hypertrophy is conjoined with a 
thickened condition of the auriculo-ventricular valves. 
On the other hand, w^here the ventricular walls are thin 
and the valves natural, the first sound becomes sharp 
and clicking in character, and the pitch is raised. The 
second sound is rendered dull and low-pitched by 
diminished elasticity of the arterial walls, and by thick- 



IRREGULARITY IN THE HEART SOUNDS. 95 

ening of the aortic valves, without regurgitation. Some- 
times the heart sounds have a metallic or tinkling qual- 
ity, which depends either upon an irritable action of the 
heart or on a gaseous distention of the stomach. 

Alterations in Seat. — This refers to the points of 
maximum intensity of the respective sounds. They 
may be displaced upward by certain changes in the ab- 
dominal viscera ; or doivnivard by tumors in the me- 
diastinum, and by hypertrophy with dilatation of the 
auricles ; or laterally by the accumulation of air or liquid 
in the pleural cavities. Malformations of the thorax 
may likewise displace them in different directions. 

Alterations in Rhythm. — It not infrequently happens 
that a distinct intermission occurs in the heart's action. 
After a certain number of regular beats, a sudden pause 
or silence occurs ; the heart's action seems to be sus- 
pended for an instant, and then to go on regularly. 
This intermission is often observed in individuals who 
are in perfect health. It also occurs in diseased states of 
the valves or orifices of the heart. It is difficult to ex- 
plain its cause, and it has no precise pathological signifi- 
cance. 

Irregularity in the HeaiH Sounds, however, constitutes 
another and different alteration in rhythm. The sounds 
become confused and tumultuous ; they are alternately 
loud and feeble ; at one time slow for two or three beats, 
and then they follow each other in rapid succession. 
When the irregularity is permanent, it is almost positive 
evidence of organic disease of the heart, the most fre- 
quent form being contraction of the mitral valves. 

One or both of the heart sounds, as vfell as the period 
of rest, may be prolonged or shortened. In hypertrophy 
of the ventricular walls the first sound is prolonged, in 
dilatation of the cavities of the ventricles it is shortened. 



96 PHYSICAL DIAGNOSIS. 

The first sound is also prolonged when the two sur- 
faces of the pericardium are adherent. An obstacle to 
the flow of the blood into the ventricles prolongs the 
period of repose. Another alteration in the rhythm of 
the heart sounds is named reduplication. Each systolic 
sound may be repeated twice for one diastolic, or the 
diastolic may occur twice for one systolic. Sometimes 
only one sound is audible. 

The essential cause of the various reduplications seems 
to be a want of synchronism between the action of the 
two sides of the heart. It may occur at all ages, and is 
as common with one sound as with the other. Intermit - 
tence is an almost constant character of reduplication, 
the sound being doubled with some beats of the heart, 
and not with others. This intermittence in some in- 
stances is undoubtedly connected with the movements 
of respiration. In laborious respiration the first sound 
may be doubled at the end of inspiration and the begin- 
ning of expiration, and the second sound at the end of 
expiration and the beginning of inspiration. Clinically, 
it is important to distinguish true doubling of the sounds 
from those false reduplications which are in reality com- 
pounded of a sound and a murmur. 



LESSOR XL 

ABNORMAL SOUNDS OF THE HEART. 

Pericardial and Endocardial Murmurs. 

The term murmurs has been applied to those adven- 
titious sounds which accompany or replace the normal 
sounds of the heart, and which are not heard in health. 
Their seat may be either within the heart at the orifices 
of the ventricles, when they are called endocardial or 
valvular murmurs ; or they may be external and in the 
pericardium, when they are termed exocardial or peri- 
cardial friction sounds. 

Pericardial Friction Sounds. — The pericardium is a 
serous membrane investing the heart, as the pleura in- 
vests the adjacent lung. We have, therefore,- when it 
is inflamed, results analogous to those which we de- 
scribed as appertaining to pleurisy — namely, dryness, 
and then plastic exudation, with the different friction 
sounds which are caused by the rubbing of the rough- 
ened surfaces upon one another during the movements 
of the heart, and, lastly, the serous effusion. This simi- 
larity sometimes makes it a nice point in diagnosis to 
distinguish a pericarditis from a pleurisy. In pericardi- 
tis the sounds are limited to the precordial area ; they 
are synchronous with the cardiac rather than the respi- 
ratory movements, and do not cease when the patient 
holds his breath. 

The different forms of the pericardial friction sounds 
have been named, like those in pleurisy, grazing, rub- 
bing, creaking, rasping, etc, Clinical experience, however, 
does not always show any definite connection between 



98 PHYSICAL DIAGNOSIS. 

the state of the serous surfaces and the quality of a fric- 
tion sound. The grazing variety belongs to the initial 
stage of the inflammation ; the other varieties occur 
after the plastic effusion, and while it is undergoing or- 
ganization. These sounds vary in intensity from the 
slight rustling which can be heard only by close atten- 
tion, to a loud rasping sound audible before your ear is 
applied to the chest. As a rule, they become more dis- 
tinct during expiration than inspiration, and while the 
patient is sitting rather than while recumbent, owing 
to the greater approximation of the pericardium to the 
chest wall during these states. 

Pericardial friction sounds may be single or double — 
that is, accompanying both the systolic and the diastolic 
movements, or either one singly. Not uncommonly the 
murmur is triple, caused by the systolic movement of 
the auricle and the systolic and diastolic movements 
of the ventricle. They may accompany the valvular 
sounds, or be independent of them. They usually con- • 
vey the impression of being superficial in comparison 
with the endocardial murmurs. They are generally re- 
stricted to the pericardial space, the point of maximum 
intensity being usually at the junction of the fourth rib 
with the sternum. They do not often last long, disap- 
pearing frequently after a few hours, or at most in a 
few days. 

A pericardial murmur is distinguished from an endo- 
cardial by its rubbing quality, by its superficial charac- 
ter, and by its not being transmitted beyond the limits of 
the heart, either along the arteries or round the left side 
to the back. It may also be distinguished from a val- 
vular murmur by its intensity varying with a change in 
the position of the patient, and by its independence of 
the heart sounds. 



PHYSICAL DIAGNOSIS. 99 

Endocardial or Valvular Murmurs. 

In endocardial murmurs the elements of quality and 
intensity hold but a subordinate place as regards either 
diagnosis or prognosis. The same murmur may be, at 
different times, blowing, grating, rubbing, or musical in 
character, without its significance altering in the least 
through all these changes in its quality. "The mere 
fact that a murmur exists, and has a certain acoustic 
quality, tells very little as regards the true character of 
a case." Practically speaking, endocardial murmurs 
may be regarded as " audible announcements" that 
something has occurred to roughen the surfaces of the 
endocardium, or to constrict the orifices of the heart, or 
to render the valves insufficient so that they allow the 
blood to regurgitate, or to diminish the elasticity of the 
great vessels, or, finally, that some change has taken 
place in the natural constituents of the blood itself. 
-Anomalous chordae tendinese, when crossing the cavity 
of the heart near its base, sometimes give rise to a musi- 
cal murmur. 

Having ascertained the existence of a cardiac mur- 
mur, the first question then is, What is its pathological 
significance, or in what way has it been produced ? To 
determine this it is necessary to observe particularly 
two points : 1st, The rhythm ; and, 2d, The seat of the 
murmur. 

The Ehythm of a Murmur. — By rhythm we mean 
the relation of a murmur to the different phases of the 
cardiac cycle. We speak of the murmur as occurring 
with the auricular or ventricular systole, or during the 
rest which intervenes between the periods of activity. 
To determine its rhythm you must carefully note its re- 
lation to the normal sounds, the impulse, and the caro- 
tid pulse. 



100 



PHYSICAL DIAGNOSIS. 



Evidently, the first step is to determine which is the 
first and which is the second sound of the heart. When 
the heart's action is slow and regular, this is an easy 
matter, but when it is rapid it is always difficult, and 
sometimes impossible, to distinguish the one sound from 
the other. It is important, therefore, not only to know 
theoretically all the appreciable phenomena of the phy- 
siological action of the heart, but to have a practical 
familiarity with them. 

Having identified the two sounds, and noted their rela- 
tion to the apex beat and carotid pulse, the rhythm of a 
murmur is readily determined; for all valvular mur- 




Fig. 12.— Diagram illustrating the mode of production of Cardiac Murmurs in the 
Left Heart, and the condition of the Valves and Cavities during their production. By 
substituting the words " tricuspid " and " pulmonary " for " mitral " and " aortic," 
the diagram will similarly illustrate murmurs occurring in the right heart. 

murs either precede, or take the place of, or immediately 
follow one of the heart sounds. 

First. A murmur may precede and run up to the first 
sound, ending at the commencement of the sound, and 
with the apex beat. In this case, as shown by Fig. 12, 
the murmur is simultaneous with the contraction of the 
auricles, and is either a mitral or tricuspid obstructive 
murmur, according as it is produced on the right or left 



THE RHYTHM OF A MURMUR. 101 

side of the heart while the blood is passing from the 
auricles to the ventricles. Such murmurs, therefore, de- 
pend upon contraction of the mitral or tricuspid orifices, 
or upon deposits on the auricular surface of these valves, 
causing obstruction to the outflow of blood from the 
auricle. 

Second. A murmur may take the place of, or follow, 
the first sound, ending somewhere between the first and 
second sounds. In this case the murmur is coincident 
with the contraction and emptying of the ventricles, and 
must be caused, as is shown in Fig. 12, either by obstruc- 
tion to the current of blood as it flows outward from the 
ventricles, in its natural direction into the aorta and pul- 
monary artery ; or backward, by regurgitation, through 
the mitral or tricuspid valves. If it occur on the left side 
of the heart, it is either an aortic obstructive or a mitral 
regurgitant murmur ; if it occur on the right side of the 
heart, it is either a pulmonic obstructive or a tricuspid 
regurgitant murmur. 

Third. A murmur may take the place of, or follow, 
the second sound, ending somewhere during the interval 
between the second and first sounds : in some instances 
it may be prolonged through the whole period of rest. 
This murmur is simultaneous with the dilatation of the 
ventricles (Fig. 12), and is produced by regurgitation of 
blood through the aortic or pulmonary valves, and is 
either an aortic regurgitant or a pulmonic regurgitant 
murmur. 

We may have, therefore, eight distinct endocardial 
murmurs, four systolic and four diastolic. Not infre- 
quently we find in practice various combinations of 
these different murmurs in the same case. For instance, 
it is not unusual to have a mitral obstructive and mi- 
tral regurgitant murmur combined, so as to appear to 
constitute one murmur ; the first sound of the heart 



102 



PHYSICAL DIAGNOSIS. 



will, however, enable you to separate the two mur- 
murs. In like manner, an aortic obstructive and re- 
gurgitant murmur are frequently combined ; here also 
the sound intervenes, and makes the rhythm quite 
plain. The greatest difficulty is when the normal sound 
is merged into the murmur, as is often the case when 
the mitral obstructive and regurgitant are combined. 

The precise pathological significance of endocardial 
murmurs is apparent from the following table : 
Table of Cardiac Murmurs. 1 



Periods of 
Heart's Action. 



Seat of Murmur. 



Systolic, 



Left side 
of heart. 



Right side 
of heart. 



Aortic 



Mitral. 



Pulmonary. 



Tricuspid 



Cause of Murmur. 
Obstruction to the onward flow 
of blood through the aortic 
orifice, or through the aorta. 

Regurgitation of blood through 
the mitral valve into the left 
auricle. 

Obstruction to the onward flow 
of blood through pulmonary 
orifice, or through pulmonary 
artery. 

Regurgitation of blood through 
the tricuspid orifice into right 
auricle. 



Diastolic. 



Left side 
of heart. 



Aortic. 



Right side 
of heart. 1 



Mitral, 



Pulmonary, 



I Tricuspid. 



Regurgitation of blood through 
the aortic orifice into left ven- 
tricle. 

Obstruction to the flow of blood 
from left auricle to left ven- 
tricle. 

Regurgitation of blood through 
the pulmonary orifice into 
right ventricle. 

Obstruction to flow of blood 
from right auricle into right 
ventricle. 



After Fuller. 



SEAT OF MURMURS. 103 

Although eight distinct valvular murmurs may occur 
in the heart, those on the right side are of such rare 
occurrence that they are of little clinical importance. If 
a murmur is heard with the first sound of the heart, it 
is almost certainly aortic obstructive or mitral regur- 
gitant ; if with the second sound, it is probably aortic 
regurgitant. 

An obstructive mitral murmur is also of comparatively 
rare occurrence : the force with which the blood passes 
from the auricle into the ventricle is ordinarily insuffi- 
cient to excite sonorous vibrations. 

Seat of Murmurs. — Having determined the rhythm of 
a murmur, the next step in the investigation is to find, 
within as narrow limits as possible, the place of its ori- 
gin. The points at which endocardial murmurs are 
produced being in the majority of cases one of the four 
valvular orifices, the first question to be settled under 
this head is, at which one of these valvular orifices it is 
produced. 

At the commencement of the examination, every 
means should be taken to determine in each particular 
case the actual size and position of the heart, together 
with its relation to the thoracic walls and to the sur- 
rounding organs, the exact point of the apex beat, and 
the character of the impulse. 

We must endeavor by careful stethoscopic examina- 
tion to determine the exact seat, and the limits of diffu- 
sion, of the murmur under observation. If the murmur 
is very loud or diffused, or if there are several murmurs 
present in the same case, it may give rise to some diffi- 
culty ; but in the large majority of cases the observer 
will be able to fix on a few points, or a few restricted 
spaces, over which each murmur is heard, there being 



104 



PHYSICAL DIAGNOSIS. 



no murmur elsewhere ; or, if not so, areas within which 
each murmur is heard with greatest intensity. 

As there are four valvular orifices at which the major 
ity of endocardial murmurs are produced, so there are 
four distinct areas over which murmurs arising at these 
orifices may be diffused. 



y±.w u 



Mil 




Fig. 13.— Diagram showing the Areas of Cardiac Murmurs. These several Areas cor- 
respond to the Different Spaces marked by the Dotted Lines, and a Capital Letter de- 
signates each Area. A, the Area of Mitral Murmurs; B, of Aortic ; C, of Tricuspid : 
and D, of Pulmonic.— Gairdner. 

The following rules will be found useful in recognizing 
these areas in actual practice : 

I. Area of Mitral Murmurs. — The maximum of in- 
tensity of mitral murmurs corresponds generally with 
the apex of the left ventricle, represented in Fig. 13 by 



AREA OF PULMONIC MURMURS. 105 

the circle A. If it is produced by regurgitation of blood 
through the mitral orifice, it is transmitted to the left 
and backward on the line of the apex beat. The area 
of diffusion in front corresponds very nearly to the circle 
A, Fig. 13, but it is heard with nearly the same intensity 
behind, between the lower border of the fifth and upper 
border of the eighth vertebrae, at the left of the spines, 
as in front. 

The area of diffusion of mitral obstructive murmurs is 
usually limited to a circumscribed space (circle A) around 
the apex of the heart. In some instances these mur- 
murs are heard with equal intensity over the whole su- 
perficial cardiac region. To the left of the apex beat, 
they are always indistinct, and are never heard behind. 

II. Area of Tricuspid Murmurs. — The area of tricus- 
pid murmurs corresponds to that portion of the right 
ventricle which is uncovered by lung tissue, indicated 
in the diagram by the triangular space C. This murmur 
is distinct and superficial in character, rarely audible 
above the third rib, and thus readily distinguished from 
the aortic and pulmonic murmurs. It is heard loudest 
near the xiphoid cartilage, and along the margins of the 
sixth and seventh costal cartilages. In cases of hyper- 
trophy and dilatation of the right side of the heart, 
usually its point of maximum intensity is at the junc- 
tion of the fourth rib with the sternum. 

III. Area of Pulmonic Murmurs. — A murmur in the 
pulmonary artery, or at the pulmonary valves, is carried 
to the ear nearly over the seat of the valves, as indicated 
by the circle D in the diagram, Fig. 13. Not infrequently 
its point of maximum intensity is an inch, or even an 
inch and a half, lower down. It is usually very super- 
ficial, and consequently very distinct. It is limited in 
its diffusion, being inaudible at the apex, and also along 



106 PHYSICAL DIAGNOSIS. 

the sternum. It is never heard in the neck, nor in the 
course of the great vessels. 

IV. Area of Aortic Murmurs. — The law of diffusion of 
aortic murmurs is not easily explained: not only are they 
heard with great intensity over the base of the heart, at 
the junction of the third rib with the sternum on the left 
side, but frequently, and not less distinctly, along the 
whole length of the sternum, as is indicated by the 
dotted lines along the edge of the sternum, in the irregu- 
lar space B, Fig. 13. Sometimes they are louder close to 
the xiphoid cartilage than at any other point. An aortic 
murmur is distinguished from all other cardiac murmurs 
by its propagation into the arteries of the neck. It is the 
most widely diffused of all cardiac murmurs, and can 
sometimes be traced to a very great distance from the 
heart. It may be heard behind near the lower angle 
of the scapula. 

To complete the diagnosis of endocardial murmurs, 
it is necessary to consider their rhythm in connection 
with their area. 

First. A murmur which immediately precedes the 
first sound of the heart may be either a mitral or tri- 
cuspid obstructive murmur, and is produced by obstruc- 
tion to the current of blood as it passes from the auricles 
into the ventricles. If it is a mitral obstructive murmur, 
its maximum of intensity will correspond to the circle 
A, Fig. 13 ; if, on the contrary, it is a tricuspid obstruc- 
tive murmur, its maximum of intensity will be within 
the triangle C. 

Second. Murmurs accompanying or following the 
first sound, and occurring between the first and second 
sounds, may be produced either in the auriculo-ventricu- 
lar or in the arterial orifices, and they have four distinct 
solutions. 



RHYTHM OF ENDOCARDIAL MURMURS. 107 

a. If it has its origin at the mitral orifice, it is a mitral 
regurgitant murmur, and is produced by regurgitation of 
the blood backward from the left ventricle into the left 
auricle. Its maximum of intensity in front will corre- 
spond to the circle A, Fig. 13, and it will be heard behind. 

b. If its origin is at the tricuspid orifice, it is a tri- 
cuspid regurgitant murmur, and is produced by regurgi- 
tation of the blood backward from the right ventricle 
into the right auricle. Its maximum of intensity will 
correspond to the triangle C, Fig. 13. 

c. If its origin is at the aortic orifice, it is an aortic 
obstructive murmur, and is produced by obstruction to 
the current of blood as it passes from the left ventricle 
into the aorta. Its maximum of intensity will corre- 
spond to the irregular space B, Fig. 13. 

d. If its origin is at the pulmonic orifice, it is a pul- 
monic obstructive murmur, and is produced by obstruc- 
tion to the current of blood as it passes from the right 
ventricle into the pulmonary artery. Its maximum of 
intensity will correspond to the circle D, Fig. 13. 

Again, murmurs accompanying or following the sec- 
ond sound of the heart may be produced at the aortic 
or pulmonic orifice, and in either case coincide with the 
dilatation of the ventricles. 

a. If the murmur has its origin at the aortic orifice, it 
is an aortic regurgitant murmur, and is produced by the 
regurgitation of the blood from the aorta backward into 
the left ventricle. Its maximum of intensity corre- 
sponds to the space B, Fig. 13. 

b. If a murmur following the second sound has its 
origin at the pulmonic orifice, it is a pulmonic regurgi- 
tant murmur, and is produced by the regurgitation of 
blood from the pulmonary artery into the right ventricle. 



108 PHYSICAL DIAGNOSIS. 

Its maximum of intensity corresponds to the space D, 
Fig. 13. 

One, two, three, and even four of the murmurs we 
have been considering, may occur in combination in the 
same case. The most frequent combinations are the 
aortic obstructive and regurgitant, heard over the area 
B, Fig. 13 ; next, the mitral obstructive and regurgitant, 
heard over the area A ; then we have various combina- 
tions of these, the aortic and mitral valves being both 
diseased. 

Murmurs occurring on the right side of the heart 
are comparatively of rare occurrence. The tricuspid 
regurgitant is the only one that is of practical im- 
portance. 

Anaimic and Functional Murmurs are soft and blowing 
in character, are always systolic, and almost always 
aortic. As regards their area, they are generally dif- 
fused, not only over the base of the heart, but along the 
course of the aorta and the vessels of the neck. 

An anaemic is distinguished from an organic murmur 
by its blowing character, by always accompanying the 
first sound of the heart, by being audible in several of 
the arteries at the same time, by not being constantly 
present, occasionally disappearing when the circulation 
is tranquil and returning when it is accelerated, by the 
presence of the general signs of anaemia, by the absence 
of the physical or general signs of organic disease of the 
heart, by entirely disappearing under treatment for relief 
of the anaemic state of the system. 

Venous Murmurs all come under the class of inorganic 
murmurs. The so-called venous hum is a continuous 
humming sound, having frequently a musical intonation. 
It is best heard over the jugular just above the clavicles, 
with the patient in a sitting or standing position. It is 



cammann's rules. 



109 



characteristic of anaemia, and is almost always associ- 
ated with an arterial anaemic murmur. 

Before leaving the subject of cardiac murmurs, I will 
give you some rules in relation to them, copied from the 
unpublished writings of the late Dr. Cammann; they are 
the result of long and careful observation, and, although 
they differ in some respects from the teachings of many 
auscultators, I have found them of great service io dia- 
gnosis. 

Cardiac Murmurs. 

AORTIC OBSTRUCTIVE : SYSTOLIC. 

" When it reaches the apex it is with diminished in- 
tensity. 

"When heard behind, it is most distinct at left of 
third and fourth vertebrae, close to their spines, and fre- 
quently extends downward along the spine in the course 
of the aorta, but with diminished intensity. Although 
the heart only extends as high as the fifth vertebra, the 
murmur is heard above that point, because here the 
aorta approaches the surface. 

AORTIC REGURGITANT : DIASTOLIC. 

" The intensity of the murmur from valve to right of 
apex may or may not increase downward, depending on 
the proximity of heart to parietes, the position of lungs, 
etc. ; it may decrease downward, however, from emphy- 
sema, supine recumbency, etc., or may perchance be 
loudest at apex, depending on proximity of heart to the 
parietes, position of the parts, condition of the mitral 
valve, etc. 

" Generally it is not heard behind, but may, toward 
inner side of lower angle of scapula, in thin subjects 



110 PHYSICAL DIAGNOSIS. 

especially, be heard in the same place where is heard the 
non-mitral regurgitant ; this non-mitral regurgitant be- 
ing the mitral regurgitant of Bellingham and others. 

" It is sometimes conveyed to left axilla. 

" The patient when recumbent may sometimes hear it 
nimself. 

XITRAL REGURGITANT : SYSTOLIC. 

" To indicate regurgitation, the murmur must be heard 
between lower border of fifth and upper border of eighth 
vertebra, at left of spine, provided the transmission of 
the sound be not interfered with by thickness of integu- 
ments, or other conditions of the parts. 

"When not heard in this place, but in 'left axilla 
and in the region of the left scapula. ' regurgitation is 
not indicated ; or, in other words, it is a non-regurgitant 
murmur, contrary to the teaching of Bellingham and 
others. 

' ' If there be a systolic murmur with a maximum of 
intensity between fifth and eighth vertebrae, at left of 
spine, it indicates regurgitation. 

"An aneurismal murmur, however, may be heard 
within the said limits, but it follows the aorta down- 
ward, gradually decreasing in intensity, without the 
abrupt termination of the regurgitant murmur. 

"We occasionally meet with mitral regurgitant mur- 
mur posteriorly, yet absent anteriorly. 

" The mitral regurgitant murmur may sometimes cease 
entirely, from such a change in the structural condition 
of the diseased valve, or from such contraction of the 
auriculo-ventricular opening, as will allow the valve to 
close so as to prevent regurgitation, there being actually 
in this case increased mechanical obstruction. 

" The following complication may exist, viz., aortic 



VARIOUS HEART SOUNDS. Ill 

obstructive systolic, with aortic regurgitant diastolic ex- 
tending to the apex, with the mitral regurgitant behind, 
without a corresponding murmur in front. 

"All these murmurs are not infrequently heard to 
right of apex, and even over the whole chest. 

"A mitral diastolic murmur we have not heard. If 
ever present, as stated by distinguished auscultators, it 
must depend upon physical condition external to the 
heart. Thus, pleuritic effusions or the like, in certain 
positions, by pressing suddenly and strongly upon the 
left auricle, may possibly force the blood with sufficient 
rapidity through an obstructed auriculo- ventricular ori- 
fice to cause an abnormal sound. 

"Some auscultators, however, deny the possibility of 
the occurrence of this murmur under any contingency 
whatever." 

Ventricular Murmurs. 

Not infrequently during the active progress of endo- 
carditis, as well as after the acute stage is passed, a mur- 
mur is heard taking the place of, or following, the first 
sound of the heart. These murmurs are not conveyed to 
the left of the apex, nor heard along the course of the 
aorta. They are undoubtedly produced within the cav- 
ity of the left ventricle, either by the roughening of the 
chordae tendinese or the ventricular surface of the mitral 
valves, or perhaps by an abnormal direction to the cur- 
rent of blood as it passes through the ventricle. They 
may properly be called ventricular murmurs, and may be 
distinguished from other murmurs by the time of their 
occurrence and by their limited area of diffusion. 

Sounds produced by the Action of the Heart which 

are neither Endocardial nor Pericardial. 
Sounds sometimes are heard in the precordial region, 



112 PHYSICAL DIAGNOSIS. 

produced by the action of the heart on the lungs. These 
sounds are mostly systolic and inspiratory: they usually 
cease when the respiratory movements are arrested. A 
blowing sound resembling a cardiac murmur may be 
produced in the lung tissue covering the heart, during a 
cardiac systole. A pulmonary cavity near enough to the 
heart to be influenced by it sometimes affords a loud 
systolic murmur. Sounds resembling rales may be pro- 
duced by the movements of the heart upon the bronchial 
tubes. Friction sounds generated in the pleura, of a 
crackling, rasping character, synchronous with the car- 
diac systole, are not infrequently heard. A friction 
sound heard behind and along the edge of the sternum 
from the second to the sixth rib is always pericardial; 
but when a friction sound is heard at other parts of the 
precordia, the diagnosis is often difficult. Pleuritic fric- 
tion sound usually ceases when the breath is held, but 
this is not always the case. 



LESSOR XIL 

SYNOPSIS OF THE PHYSICAL SIGNS OF PERICARDITIS — 
HYPERTROPHY, DILATATION, AND FATTY DEGENE- 
RATION OF HEART, AND ANEURISMS 
OF THORACIC AORTA. 

Synopsis of the Physical Signs of Pericarditis. 

The physical signs of pericarditis vary with the dif- 
ferent stages of the disease. In the early period of the 
attack, the only sign furnished by inspection and palpa- 
tion is an irritable and forcible action of the heart, and 
there is no change in the area of the precordial dulness 
on percussion. For some time the only characteristic 
sign of its presence is the pericardial friction sound. 
After a time, as the inflammation progresses, effusions 
take place into the pericardial sac, and we have the sec- 
ond stage, or stage of effusion. 

Inspection now discloses a prominence, or arching for- 
ward, of the precordial region, and a diminution in the 
respiratory movements of the left side. 

Palpation shows the point of the apex beat to be 
raised and carried to the left of its normal position ; or, 
if the quantity of the effusion be large, it is entirely 
suppressed. Sometimes, in extensive pericardial effu- 
sions, an undulatory impulse is felt. The position of 
the impulse will often be noticed to change with a 
change in the position of the patient. If the cardiac 
impulse is entirely absent when the patient is in the 
8 



114 



PHYSICAL DIAGNOSIS. 



recumbent posture, and becomes perceptible when he is 
placed in a sitting posture, you have strong presumptive 
evidence in favor of pericardial effusion. Sometimes 
when the pericardium is very greatly distended, the dia- 
phragm is depressed, and bulging can be detected in the 
epigastrium. 

Percussion. — The area of the precordial dulness is 
enlarged vertically and laterally. At the beginning, the 




Fig. 14.— Diagram showing the Pericardial Sac partially filled with Liquid, and Plas- 
tic Exudation upon the two Surfaces of the Pericardium above the level of the Liquid. 



dulness is principally increased upward, but any con- 
siderable amount of effusion is denoted by an increase 
in the width of the area of dulness at the lower portion 
of the precordial region. As the effusion increases, the 
shape of the enlarged area corresponds to the pyramidal 
form of the pericardial sac, as is represented in Fig. 14. 

When the pericardial sac is distended with liquid, the 
dulness will reach as high as the first rib : not inf re- 



PHYSICAL SIGNS OF CARDIAC HYPERTROPHY. 115 

quently it reaches an inch or more to the right of the 
sternum, and occasionally it extends from nipple to 
nipple. 

Auscultation. — The friction sound of the plastic stage 
becomes more and more indistinct until it ceases alto- 
gether. The heart sounds become feeble or are entirely 
lost, and the respiratory murmur and the vocal reso- 
nance are absent over the area of precordial dulness. 

When recovery takes place and the liquid effusion is 
absorbed, the bulging of the precordial region, which 
was present in the stage of effusion, subsides, and the 
area of dulness on percussion decreases, the friction 
sound reappears, the heart sounds become distinct, the 
apex beat resumes its normal position, the impulse re- 
gains its natural force, and the respiratory and vocal 
sounds are again heard over the space formerly occu- 
pied by the distended pericardium. 

Adhesion of the heart to the pericardium does not ad- 
mit of diagnosis, unless firm adhesions have formed be- 
tween the external surface of the pericardium and the 
adjacent tissues, which afterward cause dilatation and 
hypertrophy of the heart, accompanied by recession 
of the apex beat, retraction of the epigastrium, and 
diminished motion of the pericardial portion of the 
diaphragm during a full inspiration. 

Synopsis of the Physical Signs of Cardiac 
Hypertrophy. 

The physical signs of hypertrophy of the heart vary 
with the seat and extent of the hypertrophy. When 
the hypertrophy is general, inspection shows the action 
of the heart to be regular, and the visible impulse to be 
increased in extent and in force. In children there is a 
visible prominence of the precordial region. 



116 PHYSICAL DIAGNOSIS. 

Palpation. — The area greatly exceeds that within 
which the normal apex beat is felt, and the impulse has 
a heaving, Hf ting character. When the right ventricle 
is hypertrophied, the conducted epigastric impulse is 
strong. When the left ventricle is hypertrophied, the 
apex beat reaches further to the left than natural, some- 
times three inches below and three or four inches to the 
left of the normal position. 




A, 









Fio. 15.— Hypertrophy of Left Ventr'cle. Heart in situ, a, the Mammary Line. 
6, Vena Cava Superior, c, Aorta, d, Pulmonary Artery, e, Right Auricle. /, Right 
Ventricle, g, Left Auricle, h, Left Ventricle (normal outline), o, Hypertrophied 
Ventricle.— Rindfleisch. 

Percussion. — The area of both the superficial and 
deep-seated dulness increases laterally and downward. 
If the hypertrophy is confined to the left ventricle, the 
area of dulness on percussion may extend beyond the 
left nipple, as is shown in Fig. 15. 

If, on the other hand, the hypertrophy is confined 
to the right ventricle, the area of dulness may extend 



CARDIAC HYPERTROPHY. 117 

considerably to the right of the sternum, as is shown in 
Fig. 16. 

Auscultation. — The first sound is dull, muffled, and 
prolonged, and in some cases greatly increased in in- 
tensity. The second sound is also increased in intensity 
and more diffused than in health, and there is a dimi- 
nution or an entire absence of the respiratory murmur 
over the normal precordial region. 







/ s x --- li# 


/V^i -"' \ 




I) <& r*L ' to 




X s^\ - "A 


• \ --- — iy 


1 k!5v1--' x A/ 


i \ V "" — ' V / 


•~ IT/, /-A 
V ' ,- \'~-r" // \* 






» ^v_ s J'-'J- ' ' ' 


Ck=^--^v> 












* * ^ » 







Fig. 16.— Hypertrophy of Right Ventricle. Heart in situ. Description as in the pre- 
ceding figure. The contour of the Hypertrophied Right Ventricle is indicated by 

dots.— RlNDFLEISCH. 

When hypertrophy of the walls of the heart is at- 
tended with extensive dilatation of its cavities, the 
action of the heart is still regular, but the extent of the 
visible impulse is greatly increased, extending sometimes 
from the third intercostal space to the epigastrium. The 
apex beat may be felt as low as the ninth rib, and to 
the left of the nipple, and has a peculiar heaving 
character, so as sometimes to shake the bed of the 
patient. 



118 PHYSICAL DIAGNOSIS. 

The area of dulness may extend vertically from the 
third to the eighth rib, and, laterally, an inch to the 
right of the sternum and two or three inches to the left 
of the left nipple. Both sounds of the heart are pro- 
longed, and are often audible over the whole chest, even 
to the right of the spine. 

Dilatation of the Heart. 

Inspection. — The visible area of the apex beat is 
greatly increased, but it is difficult to determine its 
point of maximum intensity. Sometimes there is an 
undulating mofcion over the whole precordial space. 

Palpation. — By palpation you readily distinguish di- 
latation from hypertrophy by the feebleness of the car- 
diac impulse ; and although it sometimes can be felt as 
far to the left as the axillary line, there is an entire ab- 
sence of the lifting, forcible impulse which attends car- 
diac hypertrophy. Sometimes a purring thrill attends 
cardiac dilatation, especially when mitral regurgitation 
is present. 

Percussion shows a lateral increase in the area of pre- 
cordial dulness ; to the right when the right cavities are 
involved, and to the left when the left cavities are di- 
lated. The shape of the dull space remains oval. This 
point is of importance in the diagnosis between cardiac 
dilatation and pericardial effusion. 

Auscultation. — The sounds of a dilated heart are al- 
ways short, abrupt, and feeble. The second sound is 
often inaudible at the apex, and the two sounds seem 
to be of equal duration. If endocardial murmurs have 
been present, as the dilatation becomes extreme, no- 
thing is heard but a kind of swimming sound. The 
respiratory murmur is often feeble over the whole of 
the upper portion of the left lung. 



FIBROID HEAKT. 119 

Asystolism. 

Asystolism is a term ' c employed to designate that re- 
markable group of symptoms which is characteristic of 
an enduring inability in the right ventricle to empty it- 
self. " ' The physical signs are those of dilatation of the 
right side of the heart. A short time before death addi- 
tional signs occur, viz. : On palpation the cardiac im- 
pulse is feeble ; on auscultation the heart sounds, or any 
endocardial murmurs which may have been present, be- 
come gradually more and more feeble, until nothing 
is heard except a humming sound. A tricuspid regur- 
gitant murmur frequently develops when asystolism be- 
comes urgent, but before the heart is so weakened that 
it is not able to produce a murmur. If the symptoms 
of asystolism are moderate, the murmur disappears. 

Fatty Heart. 

The physical signs of fatty degeneration of the heart 
in many respects are identical with those of cardiac di- 
latation. The area of the precordial dulness is normal, 
the impulse weak or imperceptible, the apex beat indis- 
tinct and often invisible. The action of the heart is 
irregular, the first sound is short and feeble and some- 
times inaudible, the second sound prolonged and inten- 
sified. 

Fibroid Heart. 

The physical signs of cardiac fibrosis are feeble, rapid, 
irregular, intermittent heart action ; a diffused, feeble 
cardiac impulse ; weak but sharp heart sounds. The 
first sound is like the second in tone and duration. 
They closely resemble the foetal heart sounds. On per- 

1 Beau, "Considerations generates sur les Maladies duCoeur," 
Arch. Gen. de Med., 1853. 



120 PHYSICAL, DIAGNOSIS. 

cussion we find the area of dulness increased, chiefly to 
the left. The diagnosis of a fibroid heart cannot be 
made by the physical signs alone ; we must take them 
in connection with the symptoms and condition of the 
arterial system. By the physical signs we determine 
that the heart is chronically weak. If, then, we find 
evidence of a weak heart in one who has a strong 
fibroid history, and who gives signs of a general arte- 
rial fibrosis, the diagnosis is readily made. 



LESSON XIIL 

ANEURISM OF THE THORACIC AORTA AND ARTERIA 

INNOMINATA — EPIGASTRIC PULSATION — 

SUB-CLAVIAN MURMURS — VENOUS 

PULSATIONS AND MURMURS. 

Aneurisms of the Thoracic Aorta. — The thoracic 
aorta is affected by aneurism with varying degrees of 
frequency in the different parts of its course. Accord- 
ing to Sibson, who has collected the statistics of 703 
cases, 87 were at the commencement of the aorta in the 
sinuses of Valsalva ; 193 of the ascending arch, extra- 
pericardial; 14 of the ascending and transverse arch ; 
12 of the transverse arch ; 72 of the descending arch ; 
and 71 of the descending aorta. 

The physical methods employed in ascertaining the 
existence of aneurisms are inspection, palpation, per- 
cussion, and auscultation. 

Inspection. — If the aneurism presses on the superior 
vena cava, you will find the face, neck, and upper 
extremities swollen, livid, and occasionally oedematous, 
and the large veins of these regions turgid and vari- 
cose. But if the pressure is on an innominate vein, 
these effects will be observed only on the corresponding 
side. 

In some instances there is a thick, fleshy collar sur- 
rounding the lower part of the neck, due to capillary 
turgescence. As you inspect the chest, a more or less 



122 PHYSICAL DIAGNOSIS. 

extensive bulging may be observed at some point along 
the course of the aorta. The bulging may in some cases 
attain the size of a cocoanut, while in others it may be 
perceptible only on close examination. The non-exist- 
ence of a tumor does not, however, prove that there is 
no aneurism, for if the aneurismal enlargement springs 
from the posterior wall of the arch, or from the descend- 
ing arch or descending aorta, parts which are deeply 
seated, there may be no visible anterior bulging. 

When fche bulging portion is of large size, it is gene- 
rally conical in shape, the surface is smooth, and the 
skin looks tense and glazed. In most cases you will 
observe a pulsation of the tumor synchronous with the 
heart's systole; where this occurs in the anterior portion 
of the chest, there seem to be two beats within the 
thorax at the same time. Sometimes you can only de- 
tect the pulsation by bringing the eye to a level with, 
and looking across, the chest. If the aneurism is full of 
fibrin, there may be no visible pulsation. 

The position of the bulging affords a clue to the seat 
of the aneurism. Aneurism of the ascending arch pro- 
duces bulging to the right of the sternum, near the sec- 
ond costal cartilage; though when large it may extend 
into both mammary and infra-clavicular regions. Aneu- 
rism of the transverse arch causes protrusion of the 
upper part of the sternum. Aneurism of the descending 
arch protrudes to the left side of the sternum, though 
often, from the deep position of the artery in this part 
of its course, no tumor may be felt. Aneurism of the 
descending aorta shows itself on the left side of the 
spine, very rarely on the right. 

Palpation. — By the application of the hand you can 
appreciate better the size of the tumor, the nature of its 
contents (whether mostly liquid or solid), the condition 



ANEURISMS OF THE THORACIC AORTA. 123 

of the walls as regards perforation of the sternum or 
ribs, and the character of the pulsation, which is usually 
that of a blow equally diffused in all directions. Besides 
the systolic impulse, It diastolic one sometimes occurs; 
generally it is slight, sometimes, however, it is quite 
forcible. In some cases you will obtain the impulse by 
pressing with one hand on the sternum, and the other 
on the back, when by ordinary palpation you would not 
detect it. Again, if the aneurism is at the upper portion 
of the arch, by pressing the fingers down behind the 
sternum a distinct impulse will be felt. You may also 
ascertain by palpation whether there is a cessation or 
diminution of the expansive movement over the whole 
or part of one lung, and whether the vocal fremitus is 
lost over that side and over the tumor. 

The non-expansion and loss of vocal fremitus over 
the lung is due generally to the pressure of the aneurism 
on the air passages, or on the lung itself. When the 
aneurism presses on the carotid arteries, or when they 
are obstructed by coagula, a difference between the 
pulse of these arteries and their branches on the two 
sides will be noticed. 

Percussion. — There will be clulness over the promi- 
nence, or over a circumscribed space, in the neighbor- 
hood of the course of the aorta, not, however, corre- 
sponding to the size of the aneurism, unless more 
forcible percussion be made than is safe. The resist- 
ance is increased in proportion to the amount of the 
fibrin in the sac. When the lung is condensed by 
inflammation, or collapsed by obstruction of the bron- 
chus, there will be a greater area of dulness. 

Auscultation. — There are usually certain sounds or 
murmurs connected with an aneurism. In some cases 
neither are audible, owing either to the position of the 



124 PHYSICAL DIAGNOSIS. 

aneurism, to the solidity of its contents, or to the na- 
ture of its orifice. These sounds resemble those of the 
heart, and are similarly called systolic and diastolic ; 
they may be either equal to, or weaker, or louder than, 
those of the heart ; the systolic may exist aloue ; either 
or both sounds may be replaced by a murmur — for in- 
stance, there may be a systolic murmur only, or you 
may have both a systolic and a diastolic sound. The 
character of the murmur varies. It is usually short, 
abrupt, of low pitch, and as loud or louder than the 
loudest heart murmur. It may be rasping, sawing, 
filing, etc. The diastolic murmur is rarer than the sys- 
tolic, and is usually of a softer quality. Where the 
aneurism compresses a large bronchus, the respiratory 
murmur over the whole or a part of one side will be 
weak or suppressed ; on the opposite side it will be ex- 
aggerated. There is also loss of vocal resonance over 
the aneurism, and over the lung whose bronchus is 
obstructed. Where the lung is condensed from pres- 
sure, the breathing will be bronchial ; where there is 
pressure over the trachea or bronchi, the breathing may 
be stridulous, and be rightly referred to a lower point of 
production than the larynx. Where there is irritation 
of the recurrent laryngeal nerve, this type of breathing 
may come from spasm of the glottis. 

Differential Diagnosis.— -You will find that the prin- 
cipal difficulties in diagnosis are between aneurisms and 
intra- thoracic tumors. 

The latter are rare. They rarely pulsate, or, if they 
should, they will communicate to the hand a mere lift- 
ing pulsation ; in some instances malignant tumors 
have, however, a true expansive impulse. Again, in- 
tra-thoracic tumors are not usually developed entirely in 
the track of the aorta. Their area of dulness is large, 



EPIGASTRIC PULSATION. 125 

and the resistance communicated to the finger on per- 
cussion is usually great. As a rule, there are no sounds 
or murmurs connected with them, though in some cases 
where a tumor is placed over the aorta a murmur may 
occur. Tumors are more apt to produce persistent 
swelling and oedema of the upper extremities, neck, 
and face. In a case of aneurism, this latter sign may 
develop, and then disappear owing to a change in the 
direction of the pressure. Tubercular consolidation of 
one apex, if associated with a murmur in the sub- 
clavian or pulmonary artery, might be mistaken for an 
aneurism. In the former we have the physical signs of 
tuberculosis. The murmur is heard in the course of the 
pulmonary or sub-clavian artery. The dulness is not 
circumscribed, and extends outward, and not across 
the median line. 

Pulsatile Empyema, it seems to me, could hardly be 
mistaken for aneurism, although such instances are on 
record, for it does not occupy the position of an aneu- 
rism. Then you have the physical signs of effusion into 
the pleural sac, and it is attended by no sounds or 
murmurs. 

Aneurism op the Arteria Innominata is distin- 
guished from aneurism of the thoracic aorta by the 
fact that the tumor appears early on the right of the 
sternum. As it increases, it pushes forward the inner 
part of the clavicle, or extends upward into the neck. 
Its pulsation is diminished or suspended by pressure on 
the carotid or sub-clavian artery, while an aneurism of 
the aorta will not be affected by such pressure. 

Epigastric Pulsation may be produced by an aneu- 
rism of the abdominal aorta involving the cceliac axis, 
by tumors seated on the abdominal aorta, by displace- 
ment of the heart to the right, by regurgitation of blood 



126 PHYSICAL DIAGNOSIS. 

into the hepatic veins consequent upon dilatation of 
the right side of the heart, and by pulsation of the ab- 
dominal aorta. 

Not infrequently the impulse of the apex beat, the 
heart being normal and in its normal position, is com- 
municated to the epigastrium, and is mistaken for epi- 
gastric pulsation of a dilated heart. 

The right ventricle, in such cases, will usually be 
found lower than its normal position, and may even 
beat against the xiphoid cartilage. 

Sub-clavian Murmurs. — Not infrequently just below 
the clavicles, especially on the left side, a systolic mur- 
mur is heard directly over or along the course of the 
sub-clavian artery. These murmurs resemble those 
produced by pressure on arteries. It is reasonable, 
therefore, to infer that they are produced in the same 
way — the exact anatomical condition, however, which 
causes them is still unsettled. Adhesions at the apex of 
the lung have been suggested, also pressure from pul- 
monary consolidation at the apex. One thing is cer- 
tain, that they are more frequently met with in those 
persons who are tubercular than in others. They are 
often most intense during expiration. 

I have known the presence of a sub-clavian murmur 
to be taken as an evidence of aneurism. 

Veins. — A state of permanent turgescence or disten- 
tion of the jugular veins, as well as of the superficial 
veins of the upper part of the chest and neck, with or 
without pulsation, is frequently met with in the ad- 
vanced stage of many forms of cardiac disease, in tho- 
racic aneurism, and in any change in the thoracic organs 
which causes obstruction to the free passage of blood 
through the right side of the heart. 

Permanent turgescence of the jugular veins is usually 



VENOUS MURMURS. 127 

due to the distention of the right auricle ; any obstruc- 
tion, however, to the superior vena cava or innominata, 
such as compression, thrombosis, or stricture, will have 
the same effect. If the turgescence is temporary, a full 
inspiration will empty and collapse the distended veins, 
while a full expiration will increase their distention. 
On the other hand, if the turgescence is permanent, the 
condition of the veins is not affected by the respiratory 
acts. 

Venous Pulsations may be presystolic or systolic. 
They are most marked in the jugular veins immediately 
above the clavicles. 

Presystolic jugular pulsations are due to the contrac- 
tions of the right auricle, but they can seldom be appre- 
ciated except when the intra-thoracic veins are distended. 
Sometimes in a perfectly healthy person, when in a 
recumbent position, presystolic pulsation in the jugular 
veins can be seen. 

Systolic jugular pulsation occurs with the systole of 
the ventricles and indicates regurgitation into the right 
auricle with the ventricular systole. Friedreich states 
that sudden collapse of the jugular veins occurs in some 
cases of pericardial adhesions. Pulsations in the carotid 
arteries often communicate systolic pulsations to the 
jugulars. 

Venous Murmurs. — In auscultating the veins of the 
neck, besides the venous hum already referred to in 
Lesson XII. , presystolic, systolic, and diastolic murmurs 
are sometimes heard over the jugulars. 

Presystolic venous murmurs are only heard when the 
patient is in the recumbent posture, and are due to the 
passage of blood backward through the mouth of the 
internal jugular. 

Systolic venous murmurs are sometimes heard just 



128 PHYSICAL DIAGNOSIS. 

above the clavicles, especially on the right side, in cases 
of tricuspid regurgitation. 

Diastolic venous murmurs are only occasionally heard, 
and require for their production cardiac hypertrophy and 
dilatation with aneurism. 



ABDOMEN 



LESSOR XIV. 

INTRODUCTION — TOPOGRAPHY OF THE ABDOMEN — CON- 
TENTS OF THE VARIOUS REGIONS — ABDOMINAL 
INSPECTION, PALPATION, PERCUSSION, 
AND AUSCULTATION — DISEASED CON- 
DITIONS OF THE PERITONEUM. 

There are difficulties in the physical exploration of 
the abdomen which are not met with in similar exami- 
nations of the thorax. 

First. Thoracic diseases involve in their diagnosis the 
examination of only one or two organs, or their cov- 
erings, while an abdominal affection may require for 
its diagnosis the examination of ten or twelve organs. 
Thus a tumor in the left side may be either an enlarged 
mesenteric gland, or it may be connected with the stom- 
ach, spleen, kidneys, ovaries, or uterus ; or it may be a 
hernia, an abscess, an hydatid cyst, an aneurism, or, 
lastly, only a lump of faeces. 

Second. The action of the thoracic organs is regular 
and rhythmical, and their contents unvarying, while the 
action of the abdominal viscera is often irregular and in- 
termittent. An abdominal organ may also at one time 
be greatly distended and soon after be empty ; when 
filled, its contents may be solid, liquid, or gaseous, or all 
these together. The lungs and heart contain respec- 
tively the same quantities of air and blood during every 
five minutes of ordinary life, but the stomach and blad- 
der can never remain long in one condition, either full 
or empty. 



132 PHYSICAL DIAGNOSIS. 

Third. The abdominal organs are packed loosely in a 
cavity with loose walls. They therefore can be increased 
or decreased in size, so as to alter wholly their relations 
to their fellow-organs. Thus the uterus, usually the 
smallest, will, in fulfilling its natural function, become 
much the largest of all, crowding even the thoracic 
organs. In disease, a single ovary may swell into a sac 
which will fill entirely the abdominal cavity. These 
constitute the chief difficulties in the physical exami- 
nation of the abdomen, and they must always throw a 
certain degree of doubt upon all physical diagnoses di- 
rected to this part of the body. 

To facilitate our examinations, and to render our in- 
ferences more certain, it is well to divide the abdomen 
into regions by passing imaginary planes through the 
body. 

The divisions which have been proposed by different 
observers vary somewhat. The following, proposed by 
Dr. Bright, will, I think, be found most useful : 

The abdomen may be divided into three general zones 
— the epigastric, the umbilical, and the hypogastric. 

The Epigastric zone is bounded above by the dia- 
phragm, and below by a horizontal plane passing through 
the anterior extremities of the tenth rib on either side; 
carried backward, this plane will pass between the bodies 
of the first and second lumbar vertebrae. In a well- 
formed chest the cartilage of the tenth rib on either 
side offers a projection at its lower convex border, which 
can be felt without difficulty. This zone is subdivided 
into the epigastric and the right and left hypochon- 
driac regions, which correspond to the spaces bounded 
by the false ribs. 

The Umbilical zone is bounded above by the lower 
boundary of the epigastric, and below by a horizontal 



THE HYPOGASTRIC ZONE. 



133 



plane passing through the anterior and superior spinous 
processes of the ilia ; this plane, if carried backward, 
will pass between the second and third sacral spines. 

The Hypogastric zone is bounded above by the lower 
boundary of the umbilical zone, below, in the centre, 
by the upper margin of the pubes, on either side by 
Poupart's ligament. This zone occupies the whole cavity 




Fig. 17.— Diagram showing the different Regions of the Abdomen, and the Organs 
contained in each, which are visible on the removal of the Abdominal Walls. 



of the true pelvis. The umbilical and hypogastric zones 
have each three subdivisions, made by two vertical planes 
passing backward through the spinous processes of the 
pubes and the points on the tenth ribs already alluded 
to. The subdivisions of the umbilical zone thus pro- 
duced are termed the central or umbilical, and two 
lateral, or the right and left lumbar. The subdivisions 



134 PHYSICAL DIAGNOSIS. 

of the hypogastric thus produced consist of the middle 
or pubic, and the lateral or right and left iliac. 

The organs contained in these regions in health are as 
follows : 

The Epigastric region contains the whole of the left 
and a part of the right lobe of the liver, the gall bladder, 
the pyloric orifice of the stomach, the commencement of 
the duodenum, a portion of the colon, the pancreas, the 
abdominal aorta, and the cceliac axis. It is very neces- 
sary to understand the relative positions of these organs. 

The Right Hypochondriac region contains nearly the 
whole of trie right lobe of the liver, the angle of the as- 
cending and a portion of the transverse colon, the greater 
part of the duodenum, the renal capsule, and the upper 
portion of the right kidney. 

The Left Hypochondriac region contains the rounded 
cardiac portion of the stomach, at all times, and a very 
large portion of the organ when distended, the left angle 
of the colon, the spleen, and a small portion of the left 
kidney with its renal capsule. 

The Umbilical region is chiefly occupied by a portion 
of the transverse colon, the omentum, and the small 
intestines. It contains, likewise, the mesentery and its 
glands, the aorta, and the inferior vena cava, 

The Eight Lumbar region contains the caecum, the 
ascending colon, the lower and middle portions of the 
kidney, and a portion of the ureter. 

The Left Lumbar region is occupied by the descend- 
ing colon, the left kidney, and the ureter. A portion of 
the small intestine also occupies the lumbar region on 
each side. 

The Pubic or Hypogastric region, in children, con- 
tains the urinary bladder, with portions of the ureters 
(if they be distended, also in adults), the convolutions of 



PHYSICAL EXAMINATION OF THE ABDOMEN. 135 

the small intestine, and, in the female, the uterus and 
its appendages. 

The Eight Iliac region contains the " cul-de-sac" of 
the caput coli, the vermiform process, and the iliac 
vessels. 

The Left Iliac region contains the sigmoid flexure of 
the colon and the iliac vessels of that side. 

Methods Employed in the Physical Examinations of the 

Abdomen. 

They are the same, with the exception of succussion, 
as those practised in exploration of the thorax, but they 
differ in their relative importance. In thoracic exami- 
nations, auscultation is the most important method, 
while in abdominal examinations auscultation is only 
employed in determining the existence of aneurisms and 
of pregnancy. Percussion and palpation are the means 
by which we gain the most useful information concern- 
ing the contents of the abdominal cavity. 

Before considering the signs which indicate the 
changes occurring in the different affections of the 
abdominal organs, I will briefly notice the different 
method's of exploration. 

Inspection. — By it we note alterations in the shape 
and movements of the abdomen. It is most satisfacto- 
rily performed with the patient lying on the back and 
the thighs slightly flexed. In health, the abdomen is of 
an oval form, marked by elevations and depressions cor- 
responding to the abdominal muscles, the umbilicus, and 
in some degree by the form of the subjacent viscera ; it 
is larger, relatively to the size of the chest, in children 
than in adults ; more rotund, and broader inferiorly, in 
females than in males. 

Alterations in its shape due to disease are, first, en- 



136 PHYSICAL, DIAGNOSIS. 

largement, which may be general and symmetrical, as in 
ascites ; or partial and irregular, from tumors, hyper- 
trophy of organs, as the liver and spleen, or from tym- 
panitic distention of portions of the intestines by gas, as 
of the colon in typhoid fever ; second, retraction, as in 
extreme emaciation, and in several forms of cerebral 
disease ; especially is this noticeable in the tubercular 
meningitis of children. 

The respiratory movements of the abdominal walls 
bear a certain relation to the movements of the thorax. 
They are often increased when the latter are arrested, 
and vice versa. Thus, abdominal movements are in- 
creased in pleurisy, pneumonia, pericarditis, etc.; but 
decreased, or wholly suspended, when disease causes 
abdominal pain, or in peritonitis. 

Not infrequently, when inspecting the abdomen, a dis- 
tinct pulsation will be visible in the epigastric region, 
which frequently is mistaken for aneurism. The super- 
ficial abdominal veins are also at times visibly enlarged, 
indicating an obstruction to the current of blood either 
in the portal system, as in cirrhosis, or in the inferior 
vena cava. 

Mensuration is mainly useful in determining the ex- 
act increase or decrease of abdominal dropsies, visceral 
enlargements, and tumors. It is performed by means 
of a graduated tape. 

Palpation. — This method of exploration often fur- 
nishes important information. It may be performed 
with the tips of the fingers, with the whole hand, or 
with both hands, and the pressure may be slight or for- 
cible, continuous or intermitting. In order to obtain 
the greatest amount of information by palpation, the 
patient should be placed in a horizontal position, with 
the head slightly raised and the thighs flexed; some- 



PHYSICAL EXAMINATION OF THE ABDOMEN. 137 

times it is necessary to place him in a standing position 
or leaning forward. 

Indications furnished by Palpation. — By it we can 
determine the size and position of the viscera, the exist- 
ence of tumors and swellings, whether they are super- 
ficial or deep, large or small, hard or soft, smooth or 
nodulated, movable or fixed, solid or liquid, and whether 
or not they possess a motion of their own. We can also 
ascertain if tenderness exist in any portion of the ab- 
dominal cavity, and if pain is increased or relieved by 
firm pressure. 

• Percussion. — In the performance of abdominal per- 
cussion, the patient should be placed in the same posi- 
tion as for palpation, and the percussion should be for 
the most part mediate. In exploring the abdomen by 
means of percussion, the pleximeter (the finger being 
the best) should first be placed immediately below the 
xiphoid cartilage, pressed firmly down and carried along 
the median line toward the pubes, striking it all the 
way, now forcibly, now gently. The different tones 
which the stomach, colon, and small intestine furnish 
will be distinctly heard. The percussion should then be 
made laterally, alternately to one side and then to the 
other, until the whole surface is percussed (Bennet). In 
this manner the different percussion sounds of the sto- 
mach, large intestine, small intestine, and the solid vis- 
cera will be readily distinguished. Thus, the percussion 
sound elicited over a healthy abdomen may be dull, flat, 
or tympanitic. Over the central portion of the liver, 
spleen, and kidneys the percussion sound is flat; over 
that portion of either of these organs where they overlap 
the intestines or stomach it is dull, with a tympanitic 
quality. Over the stomach and intestines it is tympa- 
nitic, more so over the former than the latter. When 



138 PHYSICAL DIAGNOSIS. 

liquid occupies the abdominal cavity, over the liquid the 
percussion sound will be flat. A distended bladder or 
uterus, an enlarged liver, spleen, kidney, or mesenteric 
gland, ovarian, aneurismal, and other tumors, are recog- 
nized and their limits determined by the unnatural and 
increased area of the percussion flatness ; while, on the 
other hand, gaseous distention of the stomach or intes- 
tines is recognized by the increased area of tympanitic 
percussion. 

Auscultation. — For the physical exploration of the 
abdomen, auscultation is only of service, as we have said 
before, in the diagnosis of aneurisms, in detecting the 
f cetal heart sounds and the utero-placental murmur in 
the pregnant state. 

Our examinations of the abdominal viscera are some- 
times interfered with and rendered uncertain by changes 
that occur in the abdominal walls. Generally the ab- 
dominal walls are sufficiently thin, soft, and movable for 
us to determine with considerable accuracy the situation 
and condition of the contained organs ; if, however, 
everything is masked by layer upon layer of fat, as in 
some cases of obesity, abdominal examinations will be 
unsatisfactory. An cedematous condition of the abdomi- 
nal walls, as in Bright 's disease, may also prevent us 
from ascertaining the condition of the viscera. When 
this occurs, the surface of the abdomen presents a 
smooth, even, shiny, waxy appearance, and pits on firm 
pressure. Superficial abscess of the abdominal walls 
also occurs occasionally, and interferes greatly with the 
exploration of the abdominal cavity. You can recog- 
nize this by the circumscribed bulging, by tenderness 
on slight pressure, by the redness of the surface, and by 
the characteristic fluctuation of a superficial abscess. 

The abdominal muscles are sometimes abnormally de- 



ASCITES. 13& 

veloped, or unnaturally rigid as in tetanus, rheumatic 
inflammation, and in the early stage of peritonitis, and 
this somewhat interferes with our examinations. 



Diseased Conditions of the Peritoneum. 

Under this head may be included the various results 
of inflammatory action, ascites, etc. They all give rise 
to more or less abdominal enlargement. 

Acute Peritonitis. — By inspection we recognize in 
acute peritonitis either a diminution or an entire suspen- 
sion of abdominal respiration, the breathing becoming 
entirely thoracic. The abdomen enlarges, becomes un- 
naturally tympanitic, and there is marked tenderness on 
firm pressure. The comparative results of firm and 
slight pressure is one of the strong diagnostic marks of 
peritoneal inflammation. 

Chronic Peritonitis is almost always connected with 
tubercular or cancerous deposits in the substance and 
over the free surface of the peritoneum ; and in addition 
to the tympanitic distention of the abdomen, and the 
tenderness on firm pressure, noticed in acute peritonitis, 
liquid accumulations take place in the peritoneal cavity. 

Ascites. — A collection of liquid from any cause in the 
peritoneal cavity is termed ascites. 

Inspection. — The abdomen is always uniformly en- 
larged, and the movements of the abdomen in respi- 
ration are either suspended or limited to the epigastric 
region. The superficial abdominal veins, if the ascites 
depend upon disease of the liver, will often be found 
enlarged. 

Palpation. — If the palmar surface of the hand be ap- 
plied to the side of the abdomen at the level of the 
liquid, and light percussion be performed on the oppo- 



140 PHYSICAL, DIAGNOSIS. 

site side, a sense of fluctuation will be communicated to 
the hand. 

Percussion gives flatness at the lower and most de- 
pending portion of the abdomen, while at the upper por- 
tion, above the level of the liquid, there is a drum-like, 
tympanitic resonance. When the patient is in the erect 
posture, the tympanitic resonance is confined to the epi- 
gastrium and upper portion of the umbilical region. If 
in a recumbent posture, the tympanitic resonance will 
extend into the hypogastrium ; if placed on either side, 
the lumbar region of the opposite side becomes tym- 
panitic. 

Other diseases that occur in the peritoneum consist of 
enlargements, and may be classed under the head of ab- 
dominal tumors. 



LESSON" XV. 

PHYSICAL SIGNS OF THE ABNORMAL CHANGES IN THE 

DIFFERENT ABDOMINAL ORGANS — STOMACH — 

INTESTINES — LIVER — SPLEEN. 

Stomach. 

When this viscus is empty, or not distended with 
gas or food, there is on inspection no visible prominence 
to indicate its position, nor does palpation furnish us 
any information as to its condition. 

Percussion gives # a metallic or tympanitic resonance 
which enables us to distinguish it from the surrounding 
viscera. The line of dulness which marks the lower 
border of the liver and the inner border of the spleen 
determines the upper and lateral boundaries of the 
stomach. To ascertain the lower border, percuss gently 
downward from this line of dulness, until a slight 
change in the percussion sound indicates that you have 
reached the transverse colon (see Fig. 17, page 133). 
Opposite the inner border of the seventh rib, on the 
left side, the cardiac orifice of the organ is situated. At 
a point a little below the lower border of the liver, within 
a line drawn from the right nipple to the umbilicus, the 
pyloric orifice of the organ is situated. The lower mar- 
gin of the great " cul-de-sac " is found, generally, near 
the umbilicus. 

Diminution in the size of the stomach cannot be rec- 
ognized by physical exploration. An increase in size or 
distention of the stomach may occur from an accumu- 



142 PHYSICAL DIAGNOSIS. 

lation of gas, from large quantities of liquids or solids 
taken into the stomach ; or it may be enlarged within 
circumscribed spaces from cancerous deposit in its walls. 

Gaseous or Tympanitic distention of the stomach is 
recognized by an increase in the area of the characteris- 
tic tympanitic resonance of the organ. A distended con- 
dition of the stomach from food or drink is recognized 
by an absence of the normal resonance, and by a contin- 
uation of the dull percussion of the liYer and spleen 
downward to the umbilicus. A moderate amount of 
liquid or solid in the stomach can be determined by a 
limited area of dulness corresponding to the " cul-de-sac " 
of the organ. 

Cancer of the Stomach most frequently has its seat 
at the pyloric extremity of the organ ; but in whatever 
portion of the organ it may be developed, it can be rec- 
ognized by circumscribed dulness on percussion, where 
in health, when the stomach is empty, we should have 
tympanitic resonance. The percussion dulness elicited 
over the cancerous mass, however, has a hollow charac- 
ter which is readily distinguished from the flat percussion 
sound of a solid organ. 

By palpation a nodulated mass is readily detected, cor- 
responding to the area of percussion dulness, which is 
movable, easily grasped, and readily separated from the 
surrounding viscera. These signs, taken in connection 
with the attendant symptoms, are almost always suffi- 
cient for a positive diagnosis. 

Intestines. 

In a normal condition the large intestine furnishes 
a more amphoric percussion sound than the stomach. 
When, however, it is filled with liquid or solid accumula- 
tions, the situation of these accumulations can be marked 
out on the surface by the dulness on percussion. 



INTESTINES. 143 

The peculiar feel of such enlargements will generally 
enable you to decide as to their true character : they 
feel like no other tumors. On examining them through 
the abdominal walls, they are felt to be hard and resist- 
ant ; but if one finger be pressed steadily upon them for 
one or two minutes, they will at last indent like a hard 
snowball. There is not the slightest elasticity about 
them, and the indentation remains after the pressure is 
removed (Simpson). As these accumulations most fre- 
quently collect in the descending colon, the percussion 
sound over this portion is usually less resonant than over 
the ascending or transverse colon. According to Dr. 
Bennet, in a practical point of view it is often useful to 
determine whether a purgative by the mouth or an 
enema is likely to open the bowels most rapidly. If 
there is dulness in the left iliac fossa in the track of the 
descending colon, that portion of the intestine must be 
full of faeces, and an enema is indicated. If, on the 
other hand, the sound in the left iliac fossa is tympa- 
nitic, and in the right dull, an enema is of little service, 
as it will not extend to the caecum, and purgatives by 
the mouth are indicated. Sometimes the whole colon, 
or the transverse portion, or, what is more common, the 
sigmoid flexure of the large intestine, becomes distended 
with faecal accumulations, giving rise to circumscribed 
abdominal enlargement and to flatness on percussion 
over that portion of the abdomen which corresponds to 
the situation of the intestines. Care must be taken not 
to confound this condition with an enlarged liver, spleen, 
tumors, etc. The percussion sound over the small intes- 
tine, unless it is distended with gas, is higher pitched 
and less amphoric than that of the surrounding large 
intestine. There are no physical signs to indicate the 
abnormal changes which occur in this portion of the ah- 



144 PHYSICAL DIAGNOSIS. 

mentary canal, except an increase in the tympanitic 
resonance which exists when it is distended with gas. 

Liver. 

Our diagnosis in any case of hepatic disease rests 
mainly on the size, form, and position of the liver as de- 
termined by percussion and palpation. The first step, 
then, in studying the physical signs indicative of disease 
of this organ, is to become familiar with its normal 
boundaries. In its healthy state, the right lobe of the 
liver occupies the right hypochondrium, lying completely 
in the hollow formed by the diaphragm, rarely descend- 
ing below the free border of the ribs, or extending up- 
ward above the fifth intercostal space ; the left lobe 
reaches across to the left of the median hue an inch or 
more (see Fig. 17, page 133). 

The upper boundary of the organ is determined by per- 
cussing with moderate force from the right nipple down- 
ward until the flatness of the percussion sound indicates 
that a solid organ has been reached. Indicate this point 
with an aniline pencil. Then percuss downward from 
the axilla, and also from a point a little to the right of 
the median line in front, in the same manner, until a 
change occurs in the percussion sound. Indicate these 
points on the chest wall with the pencil. A line drawn 
through the three points marks the upper boundary of 
the liver. Generally it will be found to correspond to 
the base of the ensif orm cartilage on the median line in 
front, to the fifth intercostal space on the line of the 
right nipple, to the seventh rib in the axillary region, and 
to the ninth rib in the dorsal region. The lower boun- 
dary of the organ is determined by percussing downward 
from the line of flatness already determined, and noting 
the points where the tympanitic sounds of the stomach 



NORMAL BOUNDARIES OF LIVER. 145 

and large intestine occur. Usually it will be found to 
correspond, anteriorly, to the free border of the ribs, and 
to a point three inches below the ensiform cartilage on 
the median line ; laterally, in the axillary region, to the 
tenth intercostal space ; and posteriorly, in the dorsal 
region, to the twelfth rib. The flatness of the left lobe 
usually reaches two inches to the left of the median line. 
The whole margin of the liver, except where it comes in 
contact with the apex of the heart through the medium 
of the diaphragm, may thus be determined and marked 
out on the surface. The vertical measurements will be 
found very nearly as follows : On the right of the me- 
dian line in front, three inches ; on a line with the 
right nipple, four inches ; in the axillary region, four 
and one-half inches ; and in the dorsal region, four 
inches. The smooth edge of the lower margin of the 
liver in health, especially in thin subjects, can be dis- 
tinctly felt behind the free border of the ribs. 

The healthy liver in its normal position influences very 
little the percussion sound over the soft portion of the 
abdomen. As already stated, the sound is tympanitic 
from the free borders of the ribs to the pubes when the 
abdominal organs are normal and empty. If, therefore, 
the percussion sound is flat, and the flatness is uninter- 
rupted upward to the margin of the ribs on the right 
side, we have good reason for believing that the liver 
is the organ diseased. 

The gall bladder is found where the lower border of 
the liver passes under the ribs on the right side, at the 
tip of the ninth rib. 

The normal boundaries of the liver, already defined, 
may be greatly altered without any abnormal change 
occurring in the organ itself. These normal changes, un- 
less remembered, may lead to errors in diagnosis. Thus, 
10 



146 



PHYSICAL DIAGNOSIS. 



congenital malformations may give rise to an increase 
in the area of hepatic dulness. An accurate history of 
the patient, however, will keep us from error in such 
cases. In the examination of children, also, it should be 
remembered that the liver is proportionately larger than 
in adults. 

The practice of tight lacing may cause displacement 




Fig 18.— The volume of the Liver in Various Diseases. 5-10, Ribs. I, Position of the 
diaphragm in the highest degree of tumefaction of the liver (carcinoma). II, II, Nor- 
mal position of the diaphragm. II, III, Relative dulness. Ill, Position of the dia- 
phragm at the anterior wall of the chest, at the same time the line of dulness of the 
normal liver. IV, Edge of liver in cirrhosis. V, In the normal liver. VI, Fatty liver. 
VII, Amyloid liver. VIII, Cancer, leukaemia, adenoma. All of proportional size.— 
After Rindfleisch. 

and malformation of the liver, and thus give rise to ap- 
parent hepatic enlargement. The marks which this 
practice leaves on the chest walls will be sufficient to at- 
tract our attention and so prevent mistake. 

Diseases of the thoracic organs and abnormal condi- 
tions of the other abdominal viscera sometimes cause 



WAXY LIVER. 147 

displacement of the liver, simulating very closely hepat- 
ic enlargement : these we will consider under the head 
of differential diagnosis of diseases of the liver. 

VARIATIONS IN THE SIZE OF THE LIVER IN HEPATIC DISEASES. 

Variations in the size of the liver occur in almost every 
disease to which it is subject. 

It is increased in size in fatty liver, in waxy liver, in 
abscess of liver, in congestion, in acute hepatitis, in ob- 
struction of the bile ducts, in cancer, in hydatid cyst 
and other tumors. It is diminished in size in atrophic 
cirrhosis and in acute yellow atrophy. Enlargements of 
the liver were divided by Dr. Bright into smooth and 
irregular. Dr. Murchison has divided them into painless 
and painful enlargements. Both of these divisions, it 
seems to me, have their objections, and in giving the 
physical signs of the various diseases accompanied by 
enlargement of the organ, it is hardly practicable to 
adopt either of them exclusively. 

Fatty Liver. — In fatty infiltration of the liver the 
organ is uniformly enlarged, there are no circumscribed 
bulgings, its normal shape is unaltered, there is no ex- 
pansion of the lower ribs, it never gives rise to ascites, 
and it is not attended by any visible enlargement of the 
superficial veins. On palpation a soft, cushion-like en- 
largement is readily detected below the margin of the 
ribs on the right side, and in the epigastrium, extending 
not infrequently as low as the umbilicus ; its outer sur- 
face is smooth, and its lower margin is rounded and not 
well defined ; it is never tender on pressure. On percus- 
sion there is flatness over the surface of the abdomen 
corresponding to the enlargement. 

Waxy Liver. — In waxy or amyloid degeneration, the 
organ undergoes greater enlargement than in fatty in- 



148 PHYSICAL DIAGNOSIS. 

filtration ; it often becomes so large as to fill the whole 
abdominal cavity ; its growth is slow, usually extending 
over a period of two or three years. The enlargement 
is uniform, and the area of hepatic dulness is conse- 
quently increased on j>ercussion in every direction — 
more, however, in front than behind. There is often a 
visible tumor below the margin of the ribs, but there is 
no bulging of the ribs themselves. On palpation that 
portion of the organ below the ribs is dense, firm, and 
resistant ; the outer surface is smooth ; the lower mar- 
gin is at times sharp and well defined, at other times 
rounded and blunt. Pain and tenderness are rarely 
present, so that the portion of the organ below the ribs, 
as in fatty infiltration, can be manipulated without giv- 
ing the patient any inconvenience. When excessive, it 
is almost always accompanied by ascites. 

Abscess of the Liver. — An abscess may occur in any 
part of the liver. It depends entirely upon its situation 
wmether an external tumor is produced or not. If the 
abscess occupies the posterior portion of the right lobe, 
the fiver is pushed down so that its margin is perceptible 
below the free border of the ribs, and the flatness on the 
right side, posteriorly, extends higher than normal. If 
the abscess is superficial and is pointing externally, a 
distinct tumor is felt, and there is always more or less 
bulging of the ribs if the right lobe is affected. Some- 
times the organ is enormously enlarged, its free border 
extending below the umbilicus ; the surface of the en- 
largement is smooth, and it is usually tender on pres- 
sure. The sensation to the examiner on making light 
pressure will be soft and fluctuating, or that of elastic 
tenseness. In some rare instances abscesses produce 
an uneven or lobulated condition of the surface ; under 
s uch circumstances they may be mistaken for cancer, 
unless the rational symptoms and history of the case be 



CANCER OF THE LIVER. 149 

included in the elements of diagnosis. The enlargement 
goes on rapidly. With a correct history of the case, 
the diagnosis is easily made. 

Congestion of the Liver. — The most simple form 
of hepatic enlargement is that which results from con- 
gestion. When the liver is thus loaded with blood, a 
slight fulness is perceptible on the right side. On pal- 
pation the space immediately below the ribs is occu- 
pied by a smooth, hard, resisting enlargement corre- 
sponding to the natural shape of the liver. Usually it is 
not tender on pressure. There is no well-defined tumor. 

On percussion a flat sound is elicited an inch or two 
below the margin of the ribs, on the right side. 

Obstruction of the Bile Ducts will produce an en- 
largement of the liver, similar to the one just noticed, by 
preventing the outflow of bile. Sometimes, in addition 
to the general enlargement detected by the slight uni- 
form increase in the area of hepatic dulness, a globu- 
lar projection is found at a point corresponding to the 
transverse fissure. It has the elastic feel of deep- 
seated fluid. This tumor is the distended gall bladder. 

Acute Hepatitis. — The physical signs of acute hepa- 
titis do not differ materially from those of simple con- 
gestion, except in the excessive tenderness that exists 
on pressure over that portion of the organ which de- 
scends below the ribs. 

Cancer of the Liver. — In most cases of cancer the 
diagnosis is easily made. 

On Percussion the area of the hepatic dulness is al- 
ways increased, sometimes extremely so. The organ is 
found to occupy the greater portion of the epigastrium, 
extending beyond the median line into the left hypo- 
chondrium, pushing the diaphragm upward, and often 
descending below the ribs to the crest of the ilium. 



150 PHYSICAL DIAGNOSIS. 

On Palpation irregular nodules of various sizes are 
distinctly felt through the abdominal walls, projecting 
from that portion of the enlarged organ which is below 
the free border of the ribs. These prominences are 
usually harder than the surrounding hepatic tissue, and 
there is more or less tenderness on pressure over them. 
Cancer of the liver may, or may not, be accompanied by 
ascites. 

Occasionally the surface of the liver in cancer is per- 
fectly smooth, and in such cases you will be unable to 
detect the disease by the physical signs. 

Hydatid Tumors of the Liver. — Hydatid cysts, when 
small or deep-seated, cannot be detected by physical 
examination; but, when large or superficially seated, 
they are recognized by abnormal increase in the area 
of hepatic dulness, and by the globular form of the 
enlargement on the surface of the organ. Sometimes 
these cysts are so large as to cause the organ to nil a 
large portion of the abdominal, and encroach on the 
right pleural, cavity. The natural form of the organ is 
greatly altered, the enlargement taking place more in 
one direction than in another. Sometimes percussion 
over a large hydatid cyst will give rise to a characteristic 
vibration known as hydatid fremitus. This vibration is 
produced by the impulse of the smaller cysts that are 
contained in a large one. A hydatid liver encroaching 
on the thoracic cavity gives rise to flatness on percus- 
sion, and absence of respiratory sound, from the base of 
the chest upward as far as the tumor extends : the 
upper boundary of the flatness is arched. It is distin- 
guished from pleuritic effusion in that a change in the 
position of the body does not change the hue of percus- 
sion dulness. On palpation, sometimes the enlarged 
portion below the ribs has an elastic or even fluctuating 



CIRRHOSIS OF THE LIVER. 151 

feel, and if a large cyst be near the surface it may give 
rise to a sense of fluctuation. The surface over these 
enlargements is smooth, the organ is not tender on pres- 
sure, and its growth is slow. 

DECREASE IN THE SIZE OF THE LIVER. 

The liver is diminished in size in atrophic cirrhosis 
and in acute yellow atrophy. 

Cirrhosis of the Liver. — In fully developed cases of 
atrophic cirrhosis of the liver, the organ is always di- 
minished in size, and there is more or less abdominal 
dropsy. The only evidence of this disease furnished by 
inspection is a visible enlargement of the superficial 
veins. 

Percussion. — The normal area of the hepatic dulness 
is diminished. Its limits are determined as follows : if 
the abdominal cavity is distended with dropsical accu- 
mulations, the patient should be placed partly on the left 
side, so that the liquid will gravitate from the hepatic 
region ; the percussion dulness then, instead of extend- 
ing to the free border of the ribs, will often give place to 
tympanitic resonance an inch or more above their free 
margin, and instead, also, of extending across the me- 
dian line into the left hypochondrium, will rarely reach 
that line ; while the vertical measurement of hepatic 
dulness on a line with the right nipple often does not 
exceed two and a half inches. 

Palpation. — Little nodules will often be felt on the 
under surface of the liver, by making firm pressure with 
the ends of the fingers under the free border of the ribs. 
Sometimes, when the distention of the abdomen from 
dropsical accumulation has been very great, we can get 
no information by palpation until after the performance 
of paracentesis. 



152 PHYSICAL DIAGNOSIS. 

■ Atrophy of the Liver. — The only physical sign of 
atrophy of the liver is the rapid diminution in size, de- 
termined by percussion. Its surface remains smooth. 
The diminution in size is never accompanied by ascites. 

DIFFERENTIAL DIAGNOSIS OF DISEASES OF THE LIVER. 

Conditions which may lead to the erroneous diagnosis 
that the liver is diseased are f aecal accumulations in the 
ascending and transverse colon, enlargement of the right 
kidney, diseases of the stomach, displacement of the 
liver by disease in the right side of the chest, enlarge- 
ment of the spleen, tumors of the omentum, and ovarian 
tumors. 

F^cal Accumulations. — To distinguish these accu- 
mulations from enlargement of the liver, by physical 
examination, is always difficult and sometimes impossi- 
ble. They give rise to a distinct tumor, below the border 
of the ribs, which by percussion and palpation seems to 
be continuous and connected with the liver. The feel of 
these f aecal enlargements, already referred to, is charac- 
teristic. The differential diagnosis sometimes, however, 
can only be made after the trial of remedies which, acting 
freely on the bowels, remove the accumulations and cause 
the disappearance of the supposed hepatic enlargement. 

Disease of the Eight Kidney. — The right kidney 
sometimes enlarges in such a manner as to present itself 
as a tumor extending from the under surface of the 
right lobe of the liver. It may be distinguished from an 
hepatic tumor by carefully examining its relation to the 
ribs. As the patient lies on his back, the enlargement, 
instead of passing up under the ribs, dips down, so as to 
allow the finger to pass vertically between the ribs and 
the tumor. Furthermore, the position of an enlarged 
kidney is not altered by a deep inspiration. 



DISEASES OF THE LIVER. 



153 



fa 
M 

fa 



fa 
W 

fa 
O 

02 

fa 

CD 

fa 
00 
I— I 

Q 

fa 
o 



O 
fa 

fa 

PQ 

En 



cfi 
> 

& 
o 

H 

o 

<! 
b 
S3 

02 


08 

a 
■a 

o 


Cirrhosis. 

Abscess. 

Syp hilitic 
liver. 

Carcinoma. 

Echinococ- 
cus. 




o 
o 


Congestion. 
Fatty liver. 
Jaundice. 
Elephantiasis 
Amyloid. 
Leukaemia. 
Diabetes liver. 
Acute yellow 
atrophy. 




> 

o 

H 


Q 

H 


3 
O 


Cirrhosis (rare- 
ly palpable). 
Abscess. 
Carcinoma. 
Syphilitic liver. 


.•d 

31 

Ho 

S_ 


u a 

CD O . 

"Si o a 


j si 

O o3 

2-=i 

02 Q 


Fatty liver. 

Jaundice. 

Hypertrop h i c 
cirrhosis 
(somet imes 
slightly 
rounded). 

Echinococcus. 

Simple atro- 
phy. 




O 
!* 

o 

H 
H 
03 

O 

O 


-d 


Cirrhosis. 

Syphilitic liver. 

E c h inococcus 
mul t i 1 o c u - 
laris (becom- 
ing soft). 

Amyloid. 

Carcinoma. 


53 os 


Simple atro- 
phy. 
Jaundice. 
Ryperaemia. 


a 
0:3 

"t * 

° o 


Fatty liver. 

Abscess. 

Echi nococ- 
cus uniloc- 
ularis. 




H 
>; 

|3 

fa 
O 

13 
N 
02 


73 
CD 
03 
03 
© 

Si 

o 

a 


Liver abscess. 

Diabetes liver. 

Congestion. 

Jaundice. 

Fatty liver. 

Passive hyper- 
semia. 

Syphilitic liver. 

Leukaemia. 

Hypertrop h i c 
cirrhosis. 

Amyloid. 

Carcinoma. 

Echinococcus. 


"6 

0) 

'a 
3 

(3 


Simple atro- 
phy. 

Atrophic nut- 
meg liver. 

Atrophic c i r - 
rhosis. 

Syphilitic liver 
(atrophic 
form rare). 

Acute yellow 
atrophy. 





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H 

cc 
m 

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H 

fa 
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Eh 
"A 
H 

a 

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OS 

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U 


Echinococcus unilocularis (rarely 
from stasis in the portal system). 

Congestion. 

Syphilitic liver. 

Cirrhosis (atrophic). 

Echinococcus multilocularis. 

Hypertrophic cirrhosis. 

Amyloid. 

(Also in acute yellow atrophy and 
abscess due to the general sys- 
temic infection.) 


"a 

CD 

03 

< 


1 of s-< 

13? 

1 o;a 

it 

1 Ofa 




Pain, 
Present. 


Echinococ cus 
mult i 1 ocu- 
laris. 

Acute yellow 
atrophy. 

Carcinoma. 

Syphilitic liver. 

Abscess. 


03 
H 
E-j 

03 


CD 

03 
CD 


Carcinoma. 

Syphilis with cic- 
atrization. 

Echinococcus mul- 
tilocularis. 

Cirrhosis. 

Adhesive p y 1 e - 
phlebitis. 

Amyloid. 

Congestion (con- 
stant in the late 
stages). j 


a 

CD 


Fatty liver. 
Elephantiasis. 
Jaundice. 
Echinococ cus 

unilocularis. 
Abscess. 




o 

s 

z 

13 
■«) 
1-5 


a 

CD 

a 
c 

CD 


Abscess. 
Congestion. 
Cirrhosis. 
Carcinoma. 
Echinococ cus 

m u It i loc - 

ularis. 
Elephantiasis. 
Jaundice. 


CD 
Si 

c3 

P3 


(Only when the 
biliary pas- 
sages are 
directly in- 
volved in the 
diseased 
processes). 

Echinococcus. 

Syphilitic liver. 


a 

CD 
03 

< 


Amyloid. 
Fatty liver. 
Adhesive pyle- 
phlebitis. 



i. - 



154 PHYSICAL DIAGNOSIS. 

Diseases of the Stomach. — The only disease of the 
stomach which we are likely to confound with enlarge- 
ment of the liver is cancer. Usually, however, it can be 
readily distinguished from hepatic enlargement by the 
tympanitic quality of the percussion sound over the 
cancerous mass, and by the mobility of the mass. 

Displacements of the Liver downward from ex- 
tensive pleuritic effusion, and from pneumothorax, are 
recognized by the presence of the physical signs which 
indicate these thoracic diseases. 

Enlargement of the Spleen and Ovarian Tumors 
are distinguished from enlargements of the liver by the 
shape of the tumor, and by the continuous and increas- 
ing flatness of the percussion sound as we pass toward 
the normal position of these organs. 

Spleen. 

The obscurity which surrounds the normal physiologi- 
cal action of the spleen is so great that its affections usu- 
ally give rise to but negative general symptoms ; and be- 
cause of its relation to the surrounding organs, it often 
presents greater difficulties in the diagnosis of its mor- 
bid conditions than is the case with any other abdominal 
organ. In health this organ occupies the upper portion 
of the left hypochondriac region, its lower border touches 
the left kidney, while its convex surface occupies the 
concavity of the diaphragm. It is bounded posteriorly 
above by the lower border of the ninth rib ; anteriorly 
by the stomach and left colon ; and interiorly by the 
free margins of the ribs. It is about four inches long 
and three wide. In its healthy condition, inspection and 
palpation furnish only negative results. 

Percussion. — To determine the boundaries of the 
spleen by percussion, it is necessary that the patient 



SPLEEN. 



155 



should lie on the right side. Its anterior border is 
readily determined because of its relation to the stomach 
and intestine. Interiorly, where the organ comes in 
contact with the kidney, it is difficult and often impos- 
sible to determine its boundary. Its superior border 
corresponds to the line which marks the change from 
dulness to pulmonary resonance. 
In disease the spleen may be increased or diminished 




Fig. 19.— Diagram representing the different Areas occupied by the Spleen in its 
various Enlargements into the Abdominal Cavity.— Bright. 



in size ; but we are rarely, if ever, able to recognize dimi- 
nution in its size during life. In most cases of splenic 
disease there is neither pain nor tenderness. The only 
reliable physical signs are those of enlargement. The 
tumor produced can scarcely be overlooked. Its charac- 
teristics are a smooth, oblong, solid mass, felt immedi- 
ately beneath the integuments, extending from under 
the ribs on the left side, a little behind the origin of the 



156 PHYSICAL DIAGNOSIS. 

cartilages ; often advancing to the median line in one 
direction, and descending to the crest of the ilium in the 
other, filling the left lumbar region at its upper part. 
This tumor is usually movable, rounded at its upper por- 
tion, and presenting an edge more or less sharp in front, 
where it is often notched and fissured. 

The principal tumors which may be mistaken for an 
enlarged spleen are, chronic abscess of the integuments, 
cancer of the stomach, enlargement of the left lobe of 
the liver, cancer of the omentum, faecal accumulation 
in the colon, disease of the left kidney, and ovarian 
disease. 

Chronic Abscess in the Abdominal Wall sometimes 
occurs precisely in the situation of an enlarged spleen, 
but it is easily distinguished from it by the superficial 
character of the swelling, and by its being too soft to 
belong to an internal viscus. 

Cancerous Deposit in the cardiac extremity of the 
stomach sometimes gives rise to a tumor, which, descend- 
ing from the margin of the ribs, might be mistaken for 
an enlarged spleen. One of the best distinctive marks 
will be found in the sound elicited by forcible percus- 
sion : it has more or less of a tympanitic resonance, 
while the tumor is harder to the feel than an enlarged 
spleen. 

Enlarged Left Lobe of the Liver is easily distin- 
guished from enlarged spleen ; for the margin of the 
tumor can be traced running toward the right, and not 
toward the left as is the case with enlarged spleen. 

Cancerous and Tubercular Enlargements of the 
omentum are distinguished from an enlarged spleen by 
the fact that they extend across the abdomen, and can- 
not be traced backward ; they do not ascend behind the 
ribs, and are rough, hard, and uneven. 



SPLEEN. 157 

F^cal Accumulation in the intestine is a source of 
very great difficulty in this diagnosis, for when it takes 
place in the descending colon, at the sigmoid flexure, the 
enlargement assumes very nearly the situation of an en- 
larged spleen, and is scarcely to be distinguished from it 
except by its peculiar feel, by its history, and by the 
results of cathartics ; nor must we conclude that the 
intestines have been emptied, without the most persever- 
ing employment of purgatives and enemata. 

The Left Kidney sometimes enlarges toward the left 
hypochondrium, and presents a tumor very nearly in the 
situation of an enlarged spleen ; but by tracing it back 
toward the loins, we shall find that its chief bulk is situ- 
ated posteriorly. It is much more fixed ; is not forced 
downward by a full inspiration ; and if the patient is 
placed on his hands and knees, it does not fall forward. 
In enlargements of the kidney, the intestine is always 
pushed forward ; this is never the case with the spleen. 
By observing the 'rules for the diagnosis of ovarian 
tumors, we shall easily distinguish them from enlarged 
spleen (Bright). 



LESSOR XVI. 

PHYSICAL SIGNS OF THE ABNORMAL CHANGES IN THE 
DIFFERENT ABDOMINAL ORGANS — CONTINUED. 

Kidneys, Bladder, Uterus, Ovaries, Aneurisms, 
Omentum, Mesentery. 

Kidneys. 

The kidneys in health are situated in the lumbar re- 
gions, as shown in Fig. 2, in the space corresponding to 
the two lower dorsal and the two upper lumbar vertebras. 
The right is a little lower than the left. Superficially, 
they extend from the eleventh rib to the crest of the 
ilium. The right is bounded above, by the posterior 
and inferior portion of the right lobe of the liver ; below, 
by the caecum ; anteriorly, by the descending portion of 
the duodenum and the ascending colon ; and posteriorly, 
by the diaphragm and quadratus lumborum. The left 
is bounded above, by the spleen ; anteriorly, by the stom- 
ach and descending colon ; inferiorly, by the descending 
colon ; and posteriorly, by the diaphragm and quadra- 
tus lumborum. 

In disease the kidneys may be increased or diminished 
in size. Diminution in the size of the kidneys can rarely 
be determined by physical examination, so that enlarge- 
ments are the only conditions to which physical ex- 
ploration is applicable. The kidneys may be enlarged 
from pyelitis, which sometimes converts them into a 
sac of pus ; cancerous and tubercular deposits, hydatid 
cysts, and simple distention, the result of an obstructed 



KIDNEYS. 159 

ureter. A tumor is sometimes developed at the upper 
border of a kidney, from disease of the suprarenal capsule. 

Inspection rarely furnishes any evidence of enlarge- 
ment of a kidney. 

Palpation of the kidney is to be practised as follows : 
The patient is placed in the dorsal position, with the 
thighs flexed. One hand is placed over the seat of the 
kidney in the lumbar region, and firm pressure is made. 
The fingers of the other hand are placed below the free 
border of the ribs, on a line running through the middle 
of Poupart's ligament. With each expiration the fingers 
are pressed deeper and deeper until the renal tumor is 
reached. The part of the abdomen in which the enlarged 
kidney is felt will vary according to the nature of the 
disease and the portion of the kidney involved. 

Percussion. — Unless the kidney is much enlarged, the 
results of percussion are uncertain. In performing per- 
cussion, the patient should be placed on the abdomen 
and chest, which posture will allow liquid accumula- 
tions in the abdominal cavity to gravitate forward, and 
the intestines to float upward. The external margin 
of the kidney is determined when the tympanitic note of 
the intestine is reached. Any enlargement will be ac- 
companied by a corresponding increase in the area of 
renal dulness. We can rarely establish by a physical 
examination the exact nature of the disease to which the 
increase in size is due. 

The sources of error in the diagnosis of enlargements 
of the kidneys vary, according as the right or left kidney 
is the seat of disease. 

Enlargement of the right kidney may be mistaken for 
a tumor of the right lobe of the liver, for cancer of the 
pyloric extremity of the stomach, for faecal distention of 
the colon, and for enlargement of the right ovary. The 



160 PHYSICAL DIAGNOSIS. 

rules for distinguishing it from each of these have been 
already given in the previous section, as likewise for 
distinguishing enlargements of the left kidney from en- 
largement of the spleen, the left ovary, and from faecal 
distention of the descending colon. 

Movable Kidney. — This is not properly a disease, but 
a structural peculiarity in certain individuals. The 
right kidney is more often affected than the left. The 
attachments of the kidney are so loose that the organ 
can be displaced, either vertically or laterally, to a con- 
siderable degree, and may so approach the anterior ab- 
dominal walls as to be readily felt through them. It 
may be found in the umbilical region, or even across the 
median line. It can be detected best by drawing up the 
feet to retract the abdomen, then grasping the tumor 
with the palm of the hand. It has a smooth, rounded 
feel, and differs from mesenteric tumors or faecal ac- 
cumulations in disappearing, on gentle pressure, into the 
abdominal cavity, so that it cannot be felt. When the 
kidney is displaced, the corresponding lumbar region 
gives a tympanitic sound on percussion. 

Bladder. 

When the bladder is empty, its position cannot be 
determined by physical exploration. It can only be de- 
tected when it is distended and rises above the pubes. It 
then appears as a tumor in the hypogastric region, 
which on palpation is smooth and oval. Its rounded 
margin is easily made out by observing the tympanitic 
sound of the intestines on the one hand, and the dull 
sound of the bladder on the other. In infants, the blad- 
der is not as deep in the pelvis as in adults, consequently 
a smaller quantity of urine in the bladder can be recog- 
nized. A distended bladder can only be mistaken in 



UTERUS. 161 

the female for a gravid uterus or a uterine tumor : 
the use of a catheter removes all doubts. 

Uterus. 

The unimpregnated uterus in its normal state is situ- 
ated in the lower part of the hypogastrium, and is 
inaccessible to the touch, externally, or to percussion ; 
but when normally enlarged by impregnation, or abnor- 
mally by disease, palpation, percussion, and ausculta- 
tion furnish us with important information. 

In pregnancy, at the end of the second month, a dull 
sound on percussion, just above the pubes, indicates the 
enlarging uterus ; later, as the uterus increases in vol- 
ume and rises into the abdomen, we are able, by the 
oval tumor felt in the hypogastrium, and by the circum- 
scribed area of dulness corresponding to the situation of 
the tumor, to establish strong presumptive evidence of 
pregnancy. The presumption becomes strengthened if 
the area of the dulness increases with the regularity 
proper to gestation. But palpation and percussion are 
not sufficient to determine whether the enlargement 
of the uterus is due to pregnancy, or to some morbid 
deposit in its walls or cavity, as fibrous tumors, etc. 

After the end of the fifth month, the evidence fur- 
nished by both these methods is inferior to auscultation. 

Eules for Performing Uterine Auscultation. — The 

female should be placed on her back, with her thighs 

slightly flexed so as to relax the abdominal muscles ; 

sometimes it is well to incline the body from one side to 

the other, or forward so as to withdraw the pressure 

of the uterus from the pelvic arteries. The abdomen 

should be uncovered, as the sounds to be examined are 

of slight intensity and their area is very circumscribed. 

Their study demands close attention and perfect silence. 
11 



162 PHYSICAL DIAGNOSIS. 

The stethoscope is always to be preferred, and the ute- 
rine tumor should be auscultated successively at different 
points. 

After the fourth month of gestation, if the uterus con- 
tains a living foetus, we may hear three distinct sounds 
— the Uterine Bruit, which is evidently connected with 
the circulation of the mother ; the Foetal Heart Sound, 
and the Funic Souffle, which are connected with the 
circulation of the foetus. 

Uterine Bruit. — This sound is single, intermitting, 
and in character is a combination of the blowing and 
hissing sounds. It increases in intensity up to the 
period of labor. It is believed to depend upon the rapid 
passage of blood from the arteries into the distended 
venous sinuses of the uterus. It is synchronous with 
the maternal pulse, is subject to the same variations, 
and is always heard before the pulsation of the foetal 
heart. 

The Area over which it is audible varies. In some in- 
stances it is limited to a single point, in others it is aud- 
ible over a surface of three or four inches, and in a few 
it is heard over the whole uterine tumor, although there 
will always be one spot of greatest intensity, correspond- 
ing to the placental attachment. It is also intensified 
by uterine contractions, though at the height of the pain 
it may cease altogether. It may be modified or arrested 
by pressure on the stethoscope. 

During the first half of pregnancy it is usually heard 
with greatest intensity in the median line, a little above 
the pubes ; after the fifth month, at the lateral and in- 
ferior borders of the uterus ; and next, in order of time, 
it will be heard at the fundus. 

This sound may be confounded with the respiratory 
murmur of the mother, and with intestinal murmurs : 



FOETAL HEART SOUNDS. 163 

these murmurs, however, are not synchronous with the 
pulse of the mother, and if this fact is remembered there 
will be little difficulty in distinguishing them. As a 
proof of pregnancy, uterine bruit is not positive, as it 
is sometimes heard in connection with uterine and ova- 
rian tumors. It does not prove that the foetus is alive, 
for it is heard for a long time after its death. Its nega- 
tive evidence is of less value, for if the placenta is attached 
posteriorly we may not be able to hear it, although 
pregnancy exist. 

Funic Souffle. — This sound is usually heard at a point 
quite remote from the uterine bruit. It is short, fee- 
ble, and blowing in character, and corresponds in preg- 
nancy with the foetal pulsation. It is supposed to depend 
upon obstruction to the transmission of blood through 
the umbilical arteries, as from twirling or knotting of 
the funis, or from external pressure. It is not a con- 
stant, nor even a frequent sound, the conditions of its 
production being rarely met with. 

Foetal Heart Sound. — This sound consists of a suc- 
cession of short, rapid, double pulsations, varying in 
frequency from 120 to 140 per minute. The first sound 
is short, feeble, and obscure, while the second, the one 
we usually hear, is loud and distinct, and may be heard 
generally over the body of the child. This sound has 
been aptly compared to the ticking of a watch wrapped 
in a napkin, and usually is first heard at the middle 
of the fourth month. The frequency of the pulsations 
does not vary with the age of the foetus. 

The extent over which the foetal heart sound is aud- 
ible varies ; usually it is transmitted over a space three 
or four inches square. The location of the sound is 
determined by the position of the foetus. It lias been 
stated that whenever the maximum intensity of this 



164 PHYSICAL DIAGNOSIS. 

sound is below a horizontal line dividing the uterus into 
equal parts, it is a vertex presentation ; when above, it 
is a breech ; also, when the foetal pulsations are heard 
low down in front on the left side, that the foetus is in 
the first position ; if heard below and in front, on the 
right side, it is in the second position. 

Twin pregnancy may sometimes be determined by the 
presence of heart sounds heard at distant points over 
the uterine tumor, and by the absence of synchronism 
in the two pulsations. The sources of deception in ex- 
ploring for the foetal heart sound are the liability of 
confounding the pulsation of the iliac arteries or abdom- 
inal aorta of the mother with it. In most cases their 
situation, comparative frequency, and absence of double 
pulsation will determine their character. But a diffi- 
culty will sometimes occur in discriminating between 
them when the natural pulse is very much increased in 
frequency and the foetal diminished. Under such cir- 
cumstances we must be guided by the character of the 
sound, and whether it is, or is not, synchronous with the 
radial pulse. 

Again, in the early stage of pregnancy, the intensity 
and impulse of the maternal pulsation may render the 
feeble foetal sound inaudible. This difficulty may be 
overcome by removing the pressure of the uterine tumor 
upon the subjacent arteries, by changing the posture of 
the mother. 

During labor our examinations should be made in the 
interval between uterine contractions. 

In protracted labors, auscultation is of value in indi- 
cating to us the time for manual or instrumental inter- 
ference to save the life of the child. The indications of 
danger to the child are feebleness or excessive frequency 
of the foetal pulsation ; irregularity in its rhythm ; ab- 



OVARIES. 165 

sence of the second sound ; its complete cessation during 
uterine contraction, and the slowness of its return in the 
interval. Irregularity and feebleness are the most threat- 
ening to the life of the child. When the sound of the 
f cetal heart is heard it is a positive proof of pregnancy ; 
but its absence is not always proof that pregnancy does 
not exist, for the foetus may be dead, and in some rare 
cases the sounds may exist and be quite inaudible for a 
time, and then appear. This phenomenon is not easily 
accounted for. 

Tumors of the Uterus, whether developed on its sur- 
face, in its walls, or within its cavity, give rise to en- 
largement of the organ, which causes it to occupy a 
position corresponding to that occupied by a gravid 
uterus. The position and extent of these enlargements 
are determined in the same manner as we determine the 
size and position of the uterus in pregnancy. Deposits 
in its walls or on its surface give rise to nodules, which 
feel through the abdominal walls like hard balls, vary- 
ing in size and shape, seldom occurring singly. The 
whole mass can usually be moved from one side to the 
other. The connection of these tumors with the uterus, 
as determined by the bimanual method of examination, 
leaves little doubt as to their true character, and by 
this means we readily distinguish them from all other 
abdominal tumors. 

Ovaries. 

The ovaries in a normal state lie in the pelvic cavity, 
and their position cannot be determined by physical ex- 
ploration ; but when they become the seat of tumors, 
and have attained such dimensions that there is no long- 
er room for them in the pelvic cavity, they ascend above 
its brim and occupy more or less space among the ab- 
dominal organs. As they pass out of the pelvis, they 



166 



PHYSICAL DIAGNOSIS. 



are first noticed in the right or left iliac region, accord- 
ing as the right or left ovary is affected, and they are 
then recognized as ovarian tumors. Before these ovarian 
enlargements have attained sufficient size to attract the 
attention of the patient, they will have reached a cen- 
tral position in the abdominal cavity. They are of more 
frequent occurrence than any other forms of abdominal 




Fig. 20.— Diagram showing the Gradual Enlargement of a Tumor of the Right Ovary 
till it fills a large portion of the Abdominal Cavity.— Bright. 



tumor, and their existence is determined almost exclu- 
sively by the physical signs which they furnish. 

Inspection. — In the early part of their development, 
an uneven projection or prominence of one part of the 
abdomen will disclose the seat of the tumor, occupying 
usually the iliac or lumbar region of one side, and ex- 
tending upward to or beyond the umbilicus ; while in 
more advanced cases no inequality will be visible, but 



OVARIAN TUMORS. 167 

the rounded form of the abdomen, while the patient lies 
on her back, offers a strong contrast to the flattened 
oval appearance of ascites, or the central rounded form 
of a uterus distended by pregnancy. 

Palpation. — Ovarian tumors, when small, have a firm, 
elastic feel ; but when large, they are soft and fluctuat- 
ing. In some cases, by passing the hand gently over the 
abdomen, the extent of the tumor will be readily appre- 
ciated. At other times, the limits of the tumor cannot 
be ascertained by gentle palpation, for it occupies the 
whole of the abdomen except the concavity of the dia- 
phragm. In such cases, by making firm, but not forci- 
ble, pressure on various parts of the abdomen, we often 
detect at once a general sense of fluctuation, and ascer- 
tain inequalities which neither the eye nor the hand 
when passed gently over the surface will enable us to 
detect ; sometimes, if the abdomen is not tense, we can 
feel masses which convey the impression of more or less 
flattened or spherical bodies attached to the inside of a 
fluctuating tumor. In some cases the sense of fluctu- 
ation is very indistinct ; in others it is even more evi- 
dent than in cases of extensive ascites. 

Percussion. — The sound elicited on percussion is flat 
over that portion of the abdomen where the tumor 
comes, in contact with the inner surface of the ab- 
dominal wall ; while at the sides and above, where the 
intestines have been pushed aside and upward by the 
tumor, the percussion sound will be tympanitic ; by this 
change in the percussion sound we are enabled to mark 
out the boundaries of the tumor. 

Differential Diagnosis. — Ovarian tumors may be con- 
founded in their diagnosis with uterine enlargements, as 
pregnancy, fibroid tumors of the uterus, etc., ascites. 
hydatids of the omentum, fcecal accumulations in the 



168 PHYSICAL DIAGNOSIS. 

intestines, and enlargements of the liver, spleen, and kid- 
neys. 

They are distinguished from pregnancy hy a stethosco- 
pic examination of the tumor, which reveals in the one 
case the sounds of the foetal heart, and in the other their 
absence. They are distinguished from uterine tumors 
by their consistence, by their outline, by the difference 
in their connection and relative position to the uterus, 
and by the fact that in uterine tumors the cavity of the 
uterus, as determined by the uterine sound, is always 
elongated. The diagnosis between ovarian and abdom- 
inal dropsy is made : First. By observing the difference 
in the shape of the abdomen when the patient lies on 
her back. Ovarian tumors project forward in the centre, 
while in ascites the abdominal enlargement is uniform. 
Second. In ovarian tumors, the percussion sound is dull 
as high as the tumor extends, while at the same time 
there will be tympanitic resonance in the most depend- 
ing portion of the abdominal cavity ; in ascites, the most 
depending portion of the abdomen is always flat, the 
percussion resonance being confined to the epigastric and 
umbilical regions. Third. In ovarian dropsy, the rela- 
tive line of flatness and resonance is not altered by 
change in the posture of the patient, which is not the 
case in ascites. 

Hydatids of the omentum form a class of tumors 
which you will be unable to distinguish from ovarian 
tumors by the physical signs. The fact, however, that 
these omental enlargements are first noticed above 
the umbilicus and gradually enlarge downward, while 
ovarian are first noticed low down in the abdomen and 
gradually enlarge upward, will in most cases be suffi- 
cient for a diagnosis. 

Faecal accumulations in the large intestine may be 



ABDOMINAL ANEURISM. 169 

mistaken for ovarian tumors. The peculiar feel of such 
enlargements, already described, will enable you to dis- 
tinguish them from ovarian tumors. 

Abdominal Aneurism. 

Aneurism of the abdominal aorta usually occurs at or 
near that portion of the vessel from which the cceliac 
axis is given off, and the rupture is usually in the poste- 
rior wall of the artery. Aneurism of the cceliac axis, of 
the renal, hepatic, superior mesenteric, or splenic arte- 
ries, is of very rare occurrence, and there are no means 
by which, if they do occur, they can be distinguished 
from aneurism of the abdominal aorta. 

Inspection. — On inspecting the abdomen in a case of 
abdominal aneurism, a tumor in the epigastrium, with 
an expansive impulse, usually is discovered ; in some 
cases, however, the closest inspection reveals nothing 
abnormal. When a tumor is present, the surface of the 
abdomen over it will be rounded and smooth. When 
the aneurism is of large size, abdominal respiration may 
be diminished and thoracic increased. Enlargement of 
the superficial veins of the abdomen, and oedema of the 
lower extremities, are very rare phenomena. 

Palpation. — By palpation we can determine approxi- 
mately the size of the tumor, its position, and its im- 
pulse. 

Aneurisms of the abdominal aorta are usually felt in 
the median line, or to the left of it, on the right side, or 
on both sides. They are immovable. The impulse, if 
one exist, is systolic and expansive, although when it is 
situated high up there also may be a slight diastolic 
movement. A thrill is rarely perceptible. By compar- 
ing the pulsation in the arteries of the lower extremities 
with that of the upper, a feebleness of pulsation may be 



170 PHYSICAL DIAGNOSIS. 

detected. The surface of the tumor, when not ruptured, 
is rounded and smooth. Effusions of blood into the sur- 
rounding tissues may produce lobulations. 

Percussion. — Durness or flatness will exist over the 
tumor, unless a distended intestine lie above it. 

Auscultation. — A systolic murmur, resembling that 
produced in aneurisms of the thoracic aorta (page 123), 
is usually heard directly over the tumor in front, or op- 
posite to it along the lumbar spine ; rarely, if ever, is 
a diastolic murmur heard, though a prolonged second 
sound often exists. In some cases, the murmur is aud- 
ible when the patient is in the recumbent posture, but 
disappears when he assumes the erect posture. 1 In other 
cases, all the physical signs of aneurism are absent, and 
still we are led to suspect its existence from the rational 
symptoms, the most prominent of which is a continuous, 
deep-seated, and at times paroxysmal pain in the lum- 
bar region, which shoots down the thighs and around 
the abdomen. 

Abdominal aneurism may be mistaken : First. For 
enlargement of various organs which by its size it has 
displaced, as the liver, kidney (especially the left), and 
the spleen. The presence, however, of the physical 
signs of aneurism in such cases will enable us to refer 
the apparent enlargement to its right source. Second. 
For neuralgia, rheumatism, renal colic, etc. The 
steady, persistent, long-continued, paroxysmal jDain 
in the lumbar region, especially in male subjects, is 
strong presumptive evidence of aneurism ; and if we 
have connected with this an immovable, although per- 
haps not pulsatile, tumor along the course of the artery, 
the diagnosis of aneurism becomes almost positive. 

1 See Intra- thoracic Auscultation, p. 3$. 



OMENTAL TUMORS. 171 

Third. For disease of the spine. Here the pain, and 
possibly a curvature produced by an aneurism, may mis- 
lead, but the physical signs of aneurism in most cases 
will correct the mistake. Fourth. For psoas or lumbar 
abscess. In this the shape of the tumor is elongated, 
and there is neither impulse nor murmur perceptible. 
Fifth. For aortic pulsation. In aortic pulsation there 
is, however, absence of a murmur, or a thrill, or percus- 
sion dulness, and the impulse is quick and jerking, and 
not expansive as in aneurism. Sixth. For abdominal 
tumors. The tumors which are apt to be mistaken for 
aneurism are enlarged left lobe of liver, cancer of the py- 
lorus, enlarged mesenteric glands, f secal accumulations, 
and hydro- or pyo-nephritic kidney. In tumors the feel 
is usually harder, the impulse lifting, rarely expansive, 
and they may be accompanied by ascites, oedema, or en- 
larged abdominal veins, the infrequency of which in 
aneurism has already been alluded to. If a murmur oc- 
cur with a non-aneurismal tumor, it may be made to 
disappear in most instances by causing the patient to 
assume a posture on his hands and knees ; the impulse 
may be diminished or cease at the same time. Tumors 
are also usually movable, aneurisms immovable. In 
many cases of abdominal aneurism the diagnosis is un- 
certain. 

Omental Tumors. 

The omentum may be the seat of a hydatid cyst, of 
cancer, or of tubercular deposits. These deposits or 
growths give rise to tumors which are readily detected 
through the abdominal walls, both by percussion and 
palpation. They are first recognized high up in the ab- 
dominal cavity, above the umbilicus, and gradually ex- 
tend downward. If there are no adhesions, you can 
push the tumors upward and from right to left. They 



172 PHYSICAL DIAGNOSIS. 

are superficial, and their uneven surface is readily de- 
tected by passing the hand lightly over the surface of 
the abdomen. They are always more or less tender 
on firm pressure. They do not move on deep inspira- 
tion, and ascites is usually an accompanying symptom. 
The percussion sound elicited over these tumors is never 
flat, but has a tympanitic quality, caused by the subja- 
cent intestines. 

Mesente ric En largements. 

Mesenteric enlargements occupy a position correspond- 
ing to that of the small intestine. They are beyond 
the reach of physical diagnosis, except as they occur in 
children in the last stage of tabes mesenterica ; then 
their diagnosis is of little practical use, their cure being 
hopeless. 



EXAMINATION OF URINE. 



LESSOR XVII. 

INTRODUCTION — PLAN OF EXAMINATION — PHYSICAL 
CHARACTERS— CHEMICAL CHARACTERS— (a) NOR- 
MAL ELEMENTS, (b) ABNORMAL ELEMENTS. 

Gentlemen : — You will find that the examination of 
the urine is of great service in the diagnosis of disease. 
In order that it shall be complete, the urine should be 
examined both chemically and microscopically. 

I shall first direct your attention to the chemical ex- 
amination. (For the microscopical examination, see 
the lesson on Clinical Microscopy.) This involves both 
qualitative and quantitative analyses — the former to 
ascertain the presence or absence of particular sub- 
stances ; the latter to determine the quantity or propor- 
tion in which they exist when present. 

The specimen to be examined should be taken from 
the urine passed a few hours after a meal or should be 
a specimen of the mixed twenty-four hours' urine, and 
should be collected in a perfectly clean bottle holding 
from four to six ounces. 

The examination should be conducted after the follow- 
ing plan: 

Physical Characters. 

1. Quantity passed in twenty-four hours. 

2. Condition (transparent or turbid). 

3. Color. 

4. Odor. 

5. Keaction. 

6. Specific gravity. 

7. Character of deposit. 



176 PHYSICAL DIAGNOSIS. 

Chemical Characters. 

NORMAL ELEMENTS. 

1. Urea. 

2. Uric acid and the urates. 

3. Phosphates. 

4. Chlorides. 

5. Sulphates. 

6. Hippuric acid and kreatinin. 

7. Xanthin bases. 

ABNORMAL ELEMENTS. 

1. Albumin. 

2. Sugar. 

3. Bile. 

4. Blood. 

5. Pus. 

The examination should be made within twelve hours 
after the urine is voided ; in warm weather, even earlier. 

Physical Characters. 

Quantity Passed in Twenty-four Hours. — The 
amount of urine voided by a healthy person in twenty- 
four hours greatly varies. The mean daily discharge 
ranges between forty and fifty fluid ounces — it may rise 
as high as eighty ounces, and fall as low as twenty-five 
ounces, and still be within the limits of health, the 
variation depending in a great degree upon the quantity 
of fluid drunk. 

In order accurately to determine the quantity passed 
in twenty- four hours, it should be carefully measured 
in a graduated urine glass. 

Before determining the clinical significance of any de- 
viation from the usual quantity of urine passed by an 



CONDITION. 177 

individual, Dr. Roberts states that the following points 
should be borne in mind : 

When the urine is unusually scanty, it should be 
ascertained, before pronouncing it a morbid phenomenon, 
whether the patient has abstained from liquids above his 
habit, or whether water has been eliminated in excess 
by some other channel, as the skin or bowels. The urine 
is always scanty in fevers, cirrhosis of the liver, and 
in some forms of Bright's disease through their entire 
course. In the early stage of acute Bright's disease 
it is very scanty, sometimes approaching or reaching 
total suppression. It is also scanty in any condition of 
the heart which directly or indirectly causes passive 
congestion of the renal veins, whereby the circulation 
through the kidneys is impeded. It becomes scanty, or 
is suppressed, in the collapse stage of cholera. 

Any diminution of the urinary secretion which ap- 
proaches suppression is of most serious import. 

The flow of urine is abundant when the surface of the 
body is cool, or when large quantities of fluid have been 
taken. In disease it is discharged in excessive quantity 
in two special maladies — diabetes and chronic interstitial 
nephritis. Temporary excess of urine occurs after hys- 
terical paroxysms, certain other convulsive attacks in 
both males and females, and after mental worry or 
anxiety. An increased tension in the arterial system, 
as in some cases of hypertrophy of the left ventricle, 
is associated with increased secretion of urine. 

Condition. — Normal urine is clear when first voided, 
but on standing a slight cloud of mucus forms. It 
comes from the urinary passages, generally the bladder. 
Urine is rendered cloudy by deposits of phosphates or 
urates, and by contamination with blood or pus. Alka- 
line fermentation produces a turbidity of the urine by 

12 



178 PHYSICAL DIAGNOSIS. 

bringing about the decomposition of urea and the pre- 
cipitation of the earthy phosphates. The presence of fat 
in the urine as an emulsion (chyluria) gives it a milky 
appearance. 

Color. — In health the color of the urine varies from 
a pale-straw to a brownish-yellow tint. This is due 
to the presence of urobilin, a normal pigment of the 
urinary secretion. But the color may be altered and yet 
indicate no morbid condition. Certain drugs impart an 
abnormal color to the urine. Ehubarb and senna give it 
a brown or reddish color ; logwood, a reddish or violet 
color ; while creosote, carbolic acid, and tar color it 
black. Santonin gives a distinct yellow color to it. 
Again, in cases of melanotic tumor the urine is dark. 
As a rule, the larger the quantity of urine passed the 
lighter the color, and vice versa. The darker color of 
the diminished amount is due to a relative excess of 
urobilin, as after great exertion which is attended by 
profuse perspiration. High-colored urine, when a nor- 
mal amount is passed, is an indication of disease. 

Bile communicates a dark olive-green tint to the 
urine. An admixture of blood gives the urine a smoky 
or distinctly reddish appearance. 

The red color of rheumatic urine is due to a special 
pigment, uroerythrin. 

Indoxyl potassium sulphate is a salt normally 
found in the urine. Sometimes, when in excess, it 
breaks down and by oxidation forms indigo-blue, which 
imparts its color to the urine. This may occur in 
Asiatic cholera and in typhus fever. 

Odor. — Healthy human urine, immediately after void- 
ing, has a sweetish, aromatic odor. But the odor may 
be chan*ged by the ingestion of certain kinds of food and 



SPECIFIC GRAVITY. 179 

the administration of certain medicines. Asparagus 
gives the urine a disagreeable stench, due to methyl 
meacaptan; cubebs, copaiba, sandal- wood oil, and garlic 
impart their odors. Turpentine produces the odor of 
violets. After alkaline fermentation the pungent odor 
of ammonia is perceptible. A fruity, apple odor is pres- 
ent in diabetes mellitus, due to the presence of acetone. 

Eeaction. — When first passed, healthy urine is slightly 
acid in reaction. This is due to the presence of acid 
sodium phosphate. The degree of acidity varies in the 
twenty -four hours. After each meal it declines for 
about two hours until the urine is neutral or even 
alkaline, and then returns to the normal. The reaction 
is affected by the kind of food eaten : thus an animal 
diet makes the urine acid ; a vegetable diet, alkaline. 
Fasting is marked by a decided increase in acidity. 

After standing for some time, all urine becomes alka- 
line from the decomposition of urea and the formation 
of ammonium carbonate. The rapidity with which this 
takes place varies with the state of the temperature. In 
warm weather the fermentation begins a few hours 
after voiding. 

In febrile and inflammatory affections, especially of 
the liver, heart, and lungs, the urine is strongly acid ; 
while in affections of the brain and spinal cord, and cer- 
tain diseases of the genito-urinary organs, it is often 
strongly alkaline. Urine that is ammoniacal when 
voided indicates chronic vesical catarrh or obstructive 
disease of the bladder or ureters. 

When the urine is mixed with blood or pus ' the re- 
action is generally alkaline. The administration of 
mineral acids gives the urine a strongly acid reaction. 

Specific Gravity. — The specific gravity of urine in 

1 In pyelitis and pyelonephritis the reaction is aeid. 



180 



PHYSICAL DIAGNOSIS. 



health varies from 1015 to 1025. When the quantity 
of urine is large the specific gravity is low, except in 
diabetes mellitus ; and when the quantity is small the 
specific gravity is high. 

The most convenient method of estimating the spe- 
cific gravity is by means of the urinometer. It consists 
of a blown-glass float, weighted with mercury, and a 
graduated stem upon which the readings are to be 
made. A cylinder of convenient size is nearly filled 
with the urine and the instrument floated in it. The 
reading should be made at the lowest point of the con- 
cave surface of the urine. 

From the specific gravity of urine a rough estimate 
may be made of the amount of solid matter contained 
in solution. The method was proposed 
by Trapp. If the reading is below 1018 
the last two figures are to be multi- 
plied by 2 ; if above, by 2.33. This will 
give the amount per thousand volumes. 
For example, in 1,500 grammes of urine 
whose specific gravity is 1030 there 
will be 104.85 grammes of solid mat- 
ter. If, then, the quantity of urine 
voided in the twenty-four hours be 
known, the daily excretion of solids 
can be approximately ascertained. 
In disease the average specific gravity of the urine 
may be increased or diminished. It is highest in dia- 
betes, and lowest in hysteria. In inflammations, as 
pneumonia, pleurisy, etc., and in fevers, it often rises 
as high as 1035. On the other hand, when the average 
specific gravity is abnormally low you may suspect some 
exhausting, non -inflammatory complaint, as Bright's 
disease, in which it may fall so low as 1002. As a rule, 




Fig. 21.— Urinometer. 



UREA. 181 

the lower the average specific gravity of the urine in 
chronic Bright 's disease, the more unfavorable the prog- 
nosis. 

Character of Deposit. — The deposit may be scant 
or heavy, amorphous or crystallized, white or colored. 
Deposits of urates are pink, reddish (brick-dust), brown, 
or white in color. Uric acid crystals form a scant red- 
dish-brown sediment resembling grains of red pepper. 
When pus is present the sediment is heavy and of a yel- 
lowish-white color. Deposits of blood are reddish in 
color. Mucus, when present in large amount, forms a 
heavy, gelatinous deposit. 

The naked-eye inspection is not to be relied upon. 
The deposit should always be examined chemically and 
microscopically. 

Chemical Characters. 

NORMAL ELEMENTS. 

Urea is a product of tissue metabolism. It is the 
chief form in which nitrogen leaves the system. The 
urea which passes off in urine is brought to the kidneys 
as such in the blood, being formed chiefly in the liver 
It is not probable that the kidneys have the power of 
forming urea by a special function. The excretion is 
subject to great variation, being dependent upon the 
amount and kind of food eaten, the amount of mental 
and physical exercise taken, etc. An animal diet in- 
creases the daily excretion, while a vegetable diet di- 
minishes it. The amount excreted in twenty-four hours 
by healthy adults varies from twenty to forty grammes 
(308. 6 to 617. 2 grains), or 1 . 5 to 2. 5 per cent. 

Quantitative Estimation of Urea. — A convenient 
ureometer has been devised by Dr. Charles Doremus for 
the rapid estimation of urea. It consists of a closed 
glass tube bent into two arms; the long arm is gradu- 



182 



PHYSICAL DIAGNOSIS. 



ST* 



- 1 

- s 



ated, the short arm is dilated into a bulb (see Fig. 22). 
Sodium hypobromite is the reagent employed. When 
urea is brought in contact with sodium hypobromite, it 
is decomposed and nitrogen gas is given off. The solu- 
tion is made by adding one cubic centimetre of bromine 
to ten cubic centimetres of a solution of sodium hydrate 
(one hundred grammes to two hundred and fifty cubic 

centimetres of water), 
and diluting with ten 
cubic centimetres of 
water. It should be 
freshly prepared for each 
examination, as it de- 
teriorates on keeping. 

The method of using 
the instrument is as fol- 
lows : Fill the ureometer 
to the mark = with the 
sodium hydrate solution, 
add one cubic centimetre 
of bromine by means of 
the pipette, and pour in 
'sufficient water to fill 
the long arm and bend. Wash the pipette, and then 
draw up one cubic centimetre of the urine to be tested. 
Introduce the tip of the pipette well into the bend, and 
force the urine out gradually. As it passes into the hy- 
pobromite solution, nitrogen gas is evolved and collects 
at the top of the tube. The reading is made after 
twenty minutes. Each division of the scale indicates 
0.001 gramme of urea for one cubic centimetre of urine. 
If, then, the number of milligrammes to the cubic cen- 



+*= 




Fig. 22.— Ureometer. 



fowler's method. 



183 



timetre be multiplied by the number of cubic centime- 
tres of urine passed, the result will be the amount of 
urea excreted in twenty-four hours. If the percentage 
by volume be desired, multiply the number of milli- 
grammes found by one hundred. An improvement on 
the Doremus apparatus is shown in Fig 23. The urine 




Fig. 23. 



is placed in the smaller tube instead of in the pipette, and 
the small stop-cock between the tubes is turned, and the 
desired amount of urine is quickly run into the large 
tube. This prevents the greater or smaller loss of gas 
so apt to occur when endeavoring to fit the tip of the 
pipette into the bend of the large tube, or when the 
urine is forced out too quickly from the pipette. 

Fowler's Method. — This method, devised by Dr. 
George B. Fowler, of New York, is based on the fact 



184 PHYSICAL DIAGNOSIS. 

that the specific gravity of urine bears a definite ratio 
to the amount of urea present. After the decomposition 
of the urea by the hypochlorites, every degree of density 
lost corresponds to 0.77 per cent, or about 3.5 grains to 
the ounce. The hypochlorite solution used is Squibb's 
solution of chlorinated soda (Labarraque's solution) seven 
parts of which will destroy the urea in one part of urine, 
unless the amount be very large, in which case the urine 
should be diluted with an equal volume of water and 
the result multiplied by two. Mix seven volumes of 
Labarraque's solution with one volume of urine; allow 
the mixture to stand for two hours with occasional shak- 
ing. Stand some of the original urine and some of 
Labarraque's solution beside the mixture, in order that 
when the specific gravity is taken the density and vol- 
ume of each will be equally affected by the temperature 
in which they have stood. Take the specific gravity 
of all three solutions to obtain the specific gravity of 
the mixture before decomposition took place ; take the 
specific gravity of Labarraque's solution, multiply by 
seven, add the specific gravity of the urine, and divide by 
eight. Subtract from this result the specific gravity of 
the mixture in which the urea has been decomposed, and 
multiply the difference by 3.5 to obtain the number of 
grains of urea per ounce, or by 0.77 to obtain the per- 
centage of urea. This is an accurate method, and is 
not interfered with by the presence of albumin or sugar. 
As the amount of urea excreted at different times 
of the day varies, being greater during the waking 
than sleeping hours, the specimen to be examined 
should be taken from the mixed urine of twenty-four 
hours. 



URIC ACID. 185 

Clinical Significance. — In disease, the quantity of 
urea contained in the urine may be abnormally increased 
or strikingly diminished. It is abnormally increased in 
all febrile affections (except yellow fever, in which it is 
diminished), in all nervous affections (especially in epi- 
lepsy), in pysemia, in diabetes, and, as a rule, in acute 
inflammation of the thoracic viscera. It is abnormally 
diminished in cholera, in some cases falling as low as 
four grammes in twenty-four hours. 

In BrigliVs disease, the diminution in the quantity 
of urea in the urine is marked and significant. As a 
rule, the more albumin in the urine the less the amount 
of urea, and vice versa. But not infrequently, in pa- 
tients with waxy or cirrhotic kidneys, the quantity of 
albumin may be slight, or for a time entirely absent (the 
urine being of low specific gravity), and still the quantity 
of urea daily excreted falls far below the normal stand- 
ard. In all forms and stages of those kidney changes 
included under the term Bright's disease, it is important 
to determine accurately the quantity of urea contained 
in each day's urine — it is an important element not only 
in diagnosis, but also in prognosis. 

Uric Acid is a normal constituent of the urine. It is 
not present as the free acid, but in combination as 
urates. The daily excretion of uric acid varies from 0.5 
to 1 gramme. Like urea, it is a product of tissue meta- 
morphosis, and is increased by an animal diet. Its pro- 
portion to urea is as 1 : 45. 

The presence of free uric acid is detected by the murex- 
ide test. Place the suspected deposit in a small cruci- 
ble with a few drops of nitric acid, and evaporate nearly 
to dryness. On the addition of a drop of ammonia a 



186 PHYSICAL DIAGNOSIS. 

rich purple color is produced. (For the microscopical 
examination see page 262.) 

To estimate the quantity of uric acid in a specimen of 
urine, add one part of hydrochloric acid to twenty parts 
of the urine, and set it aside for a day or two. The uric 
acid in the bases is replaced by the hydrochloric, and 
thrown down as yellowish or brownish crystals. These 
should be carefully separated, dried, and weighed. The 
calculation is then made for the urine of twenty-four 
hours. 

Urates. — The urates found in the urine are chiefly 
those of potassium, sodium, and ammonium ; those of cal- 
cium and magnesium may also be present. In perfectly 
healthy urine they are held in solution. Sometimes, 
however, when the amount of water is diminished, as 
after excessive perspiration, they are precipitated as the 
urine cools. The deposition of urates usually occurs in 
strongly acid urine of high specific gravity. They form 
a heavy deposit, of a pink, reddish brown, or even 
white color. These deposits are composed principally of 
acid urates. Uric acid, being a dibasic acid, can combine 
with one or two atoms of a monad metal. Two atoms 
of these metals in combination with uric acid give the 
neutral urates, and one atom gives the acid urates. 
The acid urates are much less soluble than the neutral 
urates, and are thus' more easily thrown down. Urates 
are readily dissolved b}^ heat. 

Clinical Significance. — Uric acid is not always in 
excess when it is readily precipitated. If the urine is 
very acid, it may be separated from its bases and thrown 
down. Purdy gives the conditions of the urine which 
tend to precipitation of uric acid as follows: 1. High 



PHOSPHATES. 187 

grade of acidity of the urine; 2. Poverty in mineral 
salts; 3. Low percentage of pigmentation; 4. High per- 
centage of uric acid; 5. Long standing. Any urine 
upon standing sufficiently long will deposit uric acid 
crystals in consequence of the changes culminating in 
ammoniacal decomposition. This may occur before the 
urine is voided, and be the basis of the formation of 
calculi. 

The amount of uric acid excreted is diminished in 
anaemia, chlorosis, and the advanced stages of Bright 's 
disease. It is increased in those diseases of the heart 
and lungs in which there is deficient aeration of the 
blood, in many diseases of the liver, in fevers, and in 
acute rheumatism. 

The urates are frequently deposited with the uric 
acid. Persons who habitually pass urine containing 
deposits of urates and uric acid are generally the sub- 
jects of gastric and hepatic disorders. They are usually 
large eaters and drinkers, and take little exercise. De- 
ficient oxidation is the chief cause of the uric acid 
diathesis. 

Phosphates. — The normal quantity of phosphates 
excreted in twenty-four hours has been found to be 
sbout 2.5 grammes. They are derived in part from the 
food, and in part from tissue metabolism — some have 
supposed, principally the nervous tissues. Phosphates 
of sodium, calcium, and magnesium are the salts pres- 
ent in largest amount. The calcium and magnesium 
salts constitute the earthy phosphates, the sodium and 
potassium the alkaline phosphates. As long as the urine 
is acid in reaction, the phosphates are held in solution. 
Sometimes, however, calcium phosphate is precipitated 



188 PHYSICAL DIAGNOSIS. 

upon the application of heat. In alkaline fermentation, 
urea is decomposed by a special bacterium, the micro- 
coccus ureae, with the formation of ammonium carbon- 
ate; the earthy phosphates are precipitated, and in the 
presence of ammonia the triple phosphate crystals are 
formed (see page 267). 

Deposits of phosphates are readily dissolved by a few 
drops of nitric acid. The phosphates are not always in 
excess when they are readily precipitated ; and, on the 
other hand, they may be in excess and yet remain in 
solution. They are increased in amount by a proteid 
diet and by mental or bodily exercise. 

Estimation. — Ultzmann gives a good approximate 
test for the earthy phosphates. A test tube eight inches 
in diameter is filled with urine to a depth of three 
inches, then a few drops of a solution of ammonia or 
potash are added, and the urine is heated gently till the 
phosphates separate out in flakes. The tube is then 
allowed to stand for ten minutes for the phosphates to 
settle. If the deposit equals four-tenths of an inch in 
depth the phosphates are normal ; if two or three times 
that depth they are increased ; if the deposit is only one- 
or two-tenths of an inch they are diminished. 

The test for the alkaline phosphates is made after the 
earthy phosphates are precipitated as above by acidify- 
ing the clear filtrate with acetic acid, and a few drops 
of a solution of ferric chloride (one part of the official 
solution to ten of water) are added ; a yellowish white 
precipitate will indicate the presence of phosphates. Or 
after the earthy phosphates are filtered off the ammoni- 
acal filtrate is treated with ammonio-magnesium mixture 
(one part crystallized magnesium sulphate, two parts 



PHOSPHATES. 189 

ammonium chloride, four parts ammonium hydrate, and 
eight parts distilled water) ; the alkaline phosphates are 
thrown down in a white cloud — a milky turbidity being 
considered the normal amount, a thick creamy precipi- 
tate showing excess of phosphates, while a slight turbid- 
ity shows a diminution. 

Estimation of Total Phosphates (Halliburton). — The 
following reagents are necessary: 1. A standard solu- 
tion of uranic nitrate. The uranic nitrate solution 
contains 35.5 grammes in one thousand cubic centi- 
metres of distilled water; one cubic centimetre corre- 
sponds to 0.005 gramme of phosphoric acid (P 2 5 ). 

2. An acid solution of sodium acetate. Dissolve one 
hundred grammes of sodic acetate in nine hundred cubic 
centimetres of water ; add to this one hundred cubic cen- 
timetres of glacial acetic acid. 

3. A solution of potassium ferrocyanide. 

Method : Take fifty cubic centimetres of urine ; add 
five cubic centimetres of the acid solution of sodium 
acetate; heat the mixture to boiling; run into it while 
hot the uranic nitrate solution from a burette until a 
drop of the mixture gives a distinct brown color with a 
drop of the potassium ferrocyanide solution placed on 
a porcelain slab. Eead off the amount of solution used, 
and calculate therefrom the percentage amount of phos- 
phoric acid in the urine. 

Estimation of the Earthy Phosphates. — Take two hun- 
dred cubic centimetres of urine. Render it alkaline 
with ammonia. Set the mixture aside for twelve hours. 
Collect the precipitated earthy phosphates on a filter; 
wash with dilute ammonia (1:3). Perforate the filter, 
and wash the precipitate into a beaker with water acidi- 



190 PHYSICAL DIAGNOSIS. 

fied with a few drops of acetic acid. Dissolve with the 
aid of heat, adding a little more acetic acid if necessary. 
Add five cubic centimetres of the acid sodium acetate 
solution. Dilute the mixture to fifty cubic centimetres 
with water, and estimate the phosphates with the uranic 
nitrate solution. The amount of earthy phosphates sub- 
tracted from the total phosphates will give the amount 
of alkaline phosphates. 

Clinical Significance. — Like most urinary ingredi- 
ents, the quantity of phosphates eliminated in the urine 
undergoes a marked change in disease. It has been 
found to be abnormally increased in all inflammatory 
diseases of the nervous system, in paralysis, or in any se- 
vere nerve lesion, in acute mania, in delirium tremens, 
and in rickets. It is diminished in most febrile and 
inflammatory affections, especially pneumonia (unless 
nerves or nerve centres are involved), in Bright's dis- 
ease, in gout, and in rheumatism. 

Chlorides. — Sodium chloride is the only chloride 
present in the urine in sufficient amount to claim atten- 
tion. The mean daily excretion has been computed at 
11.5 grammes. But as it is derived chiefly from the 
food, it is subject to great change. 

The test for sodium chloride consists in acidulating 
the urine with a drop or two of nitric acid and the addi- 
tion of a little silver nitrate solution. The chloride of 
silver is formed, which is insoluble in nitric acid, but 
readily soluble in ammonia. 

The quantitative estimate of the chlorides is best 
made by Sutton's modification of Mohr's test. Ten cubic 
centimetres of urine are measured into a thin porcelain 
dish, and one gramme of pure ammonium nitrate is 



CHLORIDES. 191 

added; the whole is then evaporated to dryness, and 
gradually heated over a small name to dull redness till 
all vapors are dissipated and the residue becomes white. 
It is then dissolved in a small quantity of water, and the 
carbonates produced by the combustion of the organic 
matter neutralized by dilute acetic acid; a few grains 
of pure calcium carbonate to remove all free acid are 
then added, and one or two drops of a saturated solu- 
tion of neutral potassium chromate. The mixture is 
then titrated with decinormal silver solution (16.966 
grammes of pure nitrate of silver to one thousand cubic 
centimetres of distilled water) until the end reaction, 
a pink color, appears. Each cubic centimetre of silver 
solution represents 0.005837 gramme of sodium chlo- 
ride. If 5.9 cubic centimetres of urine are taken for 
titration, the number of cubic centimetres of silver solu- 
tion used will represent the number of parts of sodium 
chloride per one thousand parts of urine. 

Clinical Significance of Chloride of Sodium. — The 
absence of chlorides in the urine is marked and constant 
in the exudative stage of acute inflammation, especially 
in pneumonia during the stage of hepatization, when 
they may be absent for two or three days, and return as 
soon as resolution commences. They are absent in a 
greater or less degree in most acute febrile diseases, as 
scarlatina, variola typhus and typhoid fevers, and re- 
current and acute yellow atrophy. Intermittent fever 
seems to be an exception to this. The chlorides are 
diminished in all acute and chronic renal diseases as- 
sociated with albuminuria, due to some extent to a di- 
minished secretion of water. They are also diminished 
in anaemic conditions and in rickets, as well as in melan- 



192 PHYSICAL DIAGNOSIS. 

cholia and in idiocy. In acute rheumatism, as soon as 
the endocardium and pericardium become implicated 
they generally suddenly disappear. Chloride of sodium 
is absent or diminished in cholera, and its increase or 
return is regarded as a very favorable symptom. 

On the other hand, an increased amount of chlorides 
is found in all conditions in which retention has previ- 
ously been present, as in the acute fevers, and in cases 
in which resorption of exudates and transudates with 
increased diuresis is taking place. In diabetes insipi- 
dus and in prurigo a great increase has been observed 
in some cases. In the acute fevers the diminution 
seems to be in ratio to the severity of the attack, while 
a continued increase, seems to indicate an improvement 
in the condition of the patient. 

The Sulphates are present in the urine in consider- 
able amounts, the average amount excreted by a nor- 
mal individual being between two and three grammes 
in twenty-four hours. They are derived from the al- 
buminous material which is constantly broken down, 
only a small portion of the inorganic sulphate being 
derived from the food. The larger portion of the sul- 
phates excreted is in the form of inorganic salts of sodi- 
um and potassium, the former predominating. About 
one-tenth, however, is in combination with organic com- 
pounds, the most important of these being the indoxyl 
and skatoxyl potassium sulphates and compounds of 
phenol, which are formed from the indol, skatol, and 
phenol produced by the putrefactive processes in the large 
intestine. The inorganic sulphates are the preformed 
sulphates, while the organic are the ethereal or com- 
bined sulphates; the ratio between the two is 10: 1. 



PHOSPHATES. 193 

The test for the sulphates consists in adding a drop or 
two of nitric acid and a few drops of a saturated solu- 
tion of barium chloride to some of the urine. A white 
precipitate insoluble in acids is formed. 

QUANTITATIVE ESTIMATES OF THE SULPHATES. (HALLIBURTON). 

Volumetric Determination. — The following solutions 
are necessary : Standard barium chloride solution — 30.5 
grammes of crystallized barium chloride in a litre of dis- 
tilled water. One cubic centimetre of this solution corre- 
sponds to 0.01 gramme of sulphuric acid (SO,). 

Solution of sulphate of potassium, twenty per cent. 

Pure hydrochloric acid. 

One hundred cubic centimetres of urine are taken in 
a beaker acidified by five cubic centimetres of hydro- 
chloric acid, and boiled. The combined sulphates are 
thus converted into ordinary sulphates, and like them 
give a precipitate with barium chloride. The solution 
is run from a burette into the mixture as long as a 
precipitate occurs, the mixture being heated before 
every addition of barium chloride to it. After adding 
five to eight cubic centimetres of the standard solution, 
allow the precipitate to settle. Place a drop of the 
clear, supernatant solution on a watch-glass, add to it 
a drop of the barium chloride solution ; if a precipitate 
occurs, add more barium chloride to the solution, and 
proceed until no more barium sulphate is formed on the 
addition of the barium chloride. Excess of the barium 
chloride must also be avoided. When only a trace of 
excess is present, a drop of the clear fluid from the 
beaker gives a cloudiness with a drop of the potassium 

sulphate solution placed on a watch-glass against a 
13 



194 PHYSICAL DIAGNOSIS. 

black ground. If more than a cloudiness appears, too 
large a quantit} 7 of barium chloride has been added, and 
the operation must be repeated. From the quantity of 
barium chloride used the percentage of sulphuric acid 
in the urine is calculated. 

Gravimetric Determination. — This method consists in 
weighing the precipitate of barium sulphate by adding 
barium chloride to a known volume of urine. One hun- 
dred parts of suphate of barium correspond to 34.33 
parts of suphuric acid (SO.J. 

Method (Salkowski): One hundred cubic centimetres 
of urine are taken in a beaker ; this is acidified with five 
cubic centimetres of hydrochloric acid, and boiled. Chlor- 
ide of barium is then added till no more precipitate occurs. 
The precipitate is collected on a small filter of known ash 
and washed with hot distilled water till no more barium 
chloride occurs in the filtrate; i.e., until the filtrate 
remains clear after the addition of a few drops of hydric 
sulphate. Then wash with hot alcohol, and afterward 
with ether. Remove the filter and place it with its con- 
tents in a platinum crucible. Heat to redness. Allow 
it to cool, then add a few drops of concentrated sulphuric 
acid to convert the small amount of barium sulphide 
formed into sulphate. Heat again to redness to drive 
off excess of sulphuric acid. Cool over sulphuric acid in 
an exsiccator; weigh, and deduct the weight of the cru- 
cible, and filter ash; the remainder is the weight of 
barium sulphate formed. 

Estimation of the Combined Sulphates (Salkowski). — 
One hundred cubic centimetres of urine are mixed with 
one hundred cubic centimetres of alkaline barium chlo- 
ride solution (two volumes of solution of barium hydrate 



PHOSPHATES. 195 

with one of barium chloride, both saturated in the cold). 
The mixture is stirred, and after a few minutes filtered; 
one hundred cubic centimetres of the filtrate (i.e., fifty 
cubic centimetres of urine) are acidified with ten cubic 
centimetres of hydrochloric acid boiled, kept at 100° C. 
on a water bath for an hour, and then allowed to stand 
till the precipitate has completely settled ; if possible, 
twenty-four hours. The further treatment of this pre- 
cipitate (equals combined sulphates) is then carried out as 
in the last case. To calculate the H 2 S0 4 , multiply the 
weight of barium sulphate by 0.4206; to calculate the 
SO s , multiply by 0.34335; to calculate the S, multiply 
by 0.13734. This method of calculation applies to the 
gravimetric estimation both of total sulphates and of 
combined sulphates. To obtain the amount of pre- 
formed sulphuric acid, subtract the amount of combined 
SO, from the total amount of S0 3 . The difference is 
the preformed SO.,. 

Clinical Significance of the Sulphates. — An increase 
in the excretion of total sulphates in the urine takes 
place whenever there is an increased tissue destruction 
in the bod} T , as in the acute febrile affections. The high- 
est amounts have been observed in the febrile stages of 
pneumonia and acute myelitis. They are also increased 
in leucsemia, diabetes mellitus, and insipidus cesopha- 
geal carcinoma, progressive muscular atrophy, pseudo- 
hypertrophic paralysis, and as a rule in chronic nephritis. 
An increased elimination seems to be caused by large 
doses of morphine, potassium bromide, sodium salicy- 
late, and antifebrin, while alcohol slightly diminishes 
the excretion. A proteid diet increases and a vegetable 
diet diminishes the amount of total sulphates excreted. 



196 PHYSICAL DIAGNOSIS. 

Of the greatest clinical importance is the elimination of 
the combined sulphates and their ratio to the preformed 
sulphates. The ethereal sulphates are increased in all 
cases of increased intestinal putrefaction, and may be 
used to measure directly the degree of this putrefaction ; 
while the normal ratio of ten to one may be greatly 
diminished. As has been shown by Drs. Herter and 
Smith, this becomes of great importance in the treat- 
ment of epileptics, when the seizures are due to the reflex 
irritation caused by the putrefactive changes occurring 
in the intestines. The ethereal sulphates are dimin- 
ished by the ingestion of the terpenes and camphor, and 
by the Carlsbad and Marienbad waters; these mineral 
waters, however, at first cause an increase. 

Other substances occurring normally in the human 
urine are hippuric acid, kreatinin, and the xanthin 
bases — xanthin, heteroxanthin, paraxanthin, hypoxan- 
thin, guanin, adenin, and carnin. Hippuric acid is 
benzoyl-amido-acetic acid, and is formed from benzoic 
acid and glycocoll; it is normally excreted in amounts 
varying from 0.1 to 1 gramme, and is increased by the 
ingestion of fruits containing benzoic acid, such as 
prunes, coffee-beans, etc. Kreatinin is derived from the 
kreatin of the muscles and the kreatin in the muscle 
tissue ingested as food. About one gramme is daily ex- 
creted by a healthy adult. The xanthin bases are un- 
doubtedly derived like uric acid from the nucleins. Their 
relation to uric acid and to each other is seen by the fol- 
lowing formulae : 

Uric acid, CsH^Oa. Paraxanthin, C 5 H 2 (CH3)N 4 0,. 

Xanthin, C 5 H 4 N 4 2 . Adenin, C 5 H 5 N 5 . 

Hypoxanthin, C 5 H 4 :N T 4 0. Guanin, C 5 H 5 N 5 0. 

Heteroxanthin, C 5 H 3 (CH 3 )N 4 2 . Carnin, C 7 H ? N 4 0,. 



ALBUMIN. 197 

The clinical significance of these substances is un- 
known. Their excretion varies in disease, but too little 
is known to justify any clinical deductions. 

Abnormal Elements. 

ALBUMIN. 

Of the different forms of albumin which have been 
found in urine, serum-albumin is the one which at pres- 
ent has most clinical significance. Numerous tests 
have been proposed for its detection, but only a few of 
them will be considered here. 

Before applying a test the urine should be rendered 
clear by filtration. When the turbidity is due to a de- 
posit of urates, a gentle heat will suffice to remove it. 

Qualitative Tests. 1. Heat and Nitric Acid Test. — 
Pour the urine into a test tube until it is about three- 
quarters full, and boil the upper portion of it — the lower 
portion is used for comparison. If a precipitate forms, 
it may be due to the presence of albumin or to an ex- 
cess of phosphates — the addition of a few drops of nitric 
acid will decide which. A precipitate of phosphates is 
readily dissolved, while the albumin is not affected or in- 
creased in amount. 

2. Hellers Test. — Pour a small quantity of nitric 
acid into a narrow test tube ; draw some of the urine 
•into a pipette and float it on the surface of the acid. If 
albumin is present, a clearly defined white band is 
formed at the junction of the two liquids. An excess of 
urates will likewise give a white band, but the upper 
border is not clearly defined, and it disappears on the ap- 
plication of a gentle heat. Dr. Charles E. Simon recom- 
mends as a great improvement on this test the using of 



198 PHYSICAL DIAGNOSIS. 

a " conical glass of about two ounces capacity instead of 
the test tube. About twenty cubic centimetres of urine 
are placed in the glass, and six to ten cubic centimetres 
of nitric acid are added by means of a pipette which is 
carried to the bottom of the vessel, when the acid is 
slowly allowed to escape." 

This test is very accurate. But a color band formed 
at the junction of the two liquids mast not be mistaken 
for albumin. 

3. Potassium Ferrocyanide and Acetic Acid Test. — 
Mix some of the urine in a test tube with an excess of 
acetic acid, and add a few drops of a ten-per-cent solu- 
tion of potassium ferrocyanide. In the presence of albu- 
min a precipitate will form, or, if the amount be small, 
only a slight turbidity will appear. 

It is especially necessary, in applying this test, to 
have the urine clear; otherwise the presence of a small 
quantity of albumin may be overlooked. 

4. Purdy's Test. — "Fill a clean test tube about two- 
thirds full of the filtered urine, and add to this about 
one-sixth of its volume of a saturated sodium chloride 
solution. Next add five to ten drops of acetic acid (fifty 
per cent), and gently boil the upper inch or so of the 
contents of the test tube for about half a minute. If 
albumin be present, even in the minutest traces, it will 
appear in the upper boiled portion of the test if exam- 
ined in a good light. This test possesses all the sensi- 
tiveness of the heat-and-acid reaction with albumin, 
while it avoids faulty reactions." 

Albumin will be found in urine that is contaminated 
with blood, pus, or the menstrual discharge. 

Quantitative Estimation. — The albuminometer gives 



ALBUMIN. 



199 



only an approximate result, but it is sufficiently accurate 
for clinical purposes. It consists of a thick glass cylin- 
der the shape of a test tube (see Fig. 24). At its upper 
portion is the mark E; about midway down, 
the mark IT; and below this, a graduated 
scale. 

The reagent used is made by dissolv- 
ing one gramme of picric acid and two 
grammes of citric acid in one hundred 
cubic centimetres of distilled water. 

The urine is poured in to the mark U, and 
the reagent added to the mark E. The 
mouth of the instrument is closed with a 
rubber stopper, and the two liquids thor- 
oughly mixed by inverting the tube several 
times. It is then set aside in the upright 
position for twenty-four hours. 

The albumin is coagulated and falls to 
the bottom. The quantity present is read 
off on the scale, each division of which cor- 
responds to 0.1 per cent. 1 

The Clinical Significance of Albumin in 
the Urine. — When albumin is found in the 
urine, the first and important question to 
decide is, whether it indicates the existence 
of organic disease of the kidneys. This 
question, however, is one which is not al- Fig. 24. 

ways easy of solution. When the symp- 
toms of acute nephritis, such as dropsy, headache, high- 
tension pulse, and anremia, are present together with a 



1 When the exact amount is desired, the albumin must be coagu- 
lated, separated by filtration, and the precipitate dried and weighed. 



200 PHYSICAL DIAGNOSIS. 

diminished quantity of urine of high specific gravity 
containing albumin and granular and epithelial casts, 
the inference is plain that we are dealing with a renal 
lesion. Or if with the symptoms of chronic nephri- 
tis, such as high-tension pulse, cardiac hypertrophy, 
oedema of the extremities, with urine of normal spe- 
cific gravity, containing albumin and casts ; or if with- 
out the oedema, and large amounts of pale urine of 
low specific gravity, with or without hyaline casts, 
and only a small quantity of albumin, the inference 
is equally plain. In the acute infectious diseases the 
albuminuria occurring in the early stages is not usu- 
ally due to a permanent lesion of the kidneys, while 
that occurring in the later weeks — ■ the second or 
third — or during convalescence more often indicates a 
more serious lesion. When there is a venous con- 
gestion due to cardiac disease or due to pressure from 
any cause, the albuminuria may result from the changes 
in the renal circulation, and does not necessarily indicate 
a concomitant nephritis. Injuries to any part of the 
genito-urinary tract may cause albuminuria. Calculi in 
the bladder or in the pelves of the kidneys may also 
cause it. The albuminuria resulting from these condi- 
tions must be differentiated by clinical examination 
from that resulting from nephritis. The "functional 
albuminurias" occurring with anaemic conditions, or with 
errors in diet or errors in the mode of living, or after 
severe muscular exertion are apt to be transitory, with 
urine of normal specific gravity, and usually appear at 
certain times in the twenty-four hours, only to disap- 
pear completely at other times. Albumin in the urine, 
therefore, appears when from any cause the blood serum 



SUGAR. 201 

becomes mixed with the urine during secretion or excre- 
tion, and the true significance must be judged by a care- 
ful scrutiny of the general systemic symptoms. 

SUGAR. 

Various forms of sugar have been found in the urine, 
but grape sugar is the only one which possesses clinical 
interest. It is not present in normal urine in sufficient 
quantity to respond to the ordinary tests. 

Urine containing sugar is usually light in color, of 
peculiar odor, and with a specific gravity varying from 
1025 to 1045, or even higher. If albumin is present, 
it must be coagulated and removed by filtration before 
examining for sugar. 

The qualitative tests most conveniently applied are 
Trommer's, Fehling's, and the Fermentation Test. 

Trommels Test. — Pour a small quantity of the urine 
into a test tube and add about one-third its volume of 
liquor potassse. A ten-per-cent solution of copper sul- 
phate is now added, drop by drop, until no more will 
dissolve. The mixture is then heated. If the urine 
contains sugar, a reddish-brown precipitate of copper 
suboxide is thrown down. 

This test is not always reliable, for chloral, uric acid, 
and bile pigment give the same reaction. 

Felilincfs Test. — The reagent employed consists of 
two solutions — a copper solution and an alkali solution 
— which should be kept separate in well-stoppered bot- 
tles, and mixed when required. The copper solution is 
made by dissolving 3-1.64 grammes of pure crystallized 
copper sulphate in one hundred cubic centimetres of 
water and diluting to five hundred cubic centimetres ; 



202 PHYSICAL DIAGNOSIS. 

the alkali solution, by dissolving one hundred and sev- 
enty-three grammes of sodium tartrate and one hundred 
grammes of caustic soda, of a specific gravity of 1031, 
in five hundred cubic centimetres of water. Equal parts 
of these solutions should be mixed when required for 
use. 

In applying the test, pour two or three cubic centime- 
tres of the reagent into a test tube, and heat to the boil- 
ing point. (If a precipitate occurs, the reagent is use- 
less.) Add an equal volume of urine, and warm but 
not boil again. If sugar is present, a reddish-brown 
precipitate is formed. If the solution becomes green 
and turbid it is due to other reducing agents not sugar. 

Fermentation Test. — Fill a large test tube with the 
suspected urine, then add a small quantity of yeast; 
close the mouth of the tube with the finger, and invert 
it in a tumbler containing a considerable quantity of the 
same urine; remove the finger without permitting air to 
enter the tube, and support it in an upright position by 
means of a small wire triangle. Set the apparatus in a 
warm place for twenty-four hours. If sugar be present, 
it will be decomposed by fermentation into alcohol and 
carbon dioxide, the gas rising to the top of the tube and 
displacing the urine; if sugar be absent, no displace- 
ment will occur. This test is reliable, provided the 
yeast is good and the temperature suitable. 

Phenyl -hydrazin Test. — This is the most reliable and 
delicate of all the tests for glucose in the urine. Two 
parts of phenyl-hydrazin hydrochloride and three parts 
of sodium acetate are placed in a test tube with six 
to eight cubic centimetres of urine. If the salts do 
not dissolve on warming, a little water is added and the 



SUGAR. 203 

test tube placed in boiling water. After twenty min- 
utes it is plunged suddenly into cold water, and if sugar 
is present the characteristic yellow crystals of phenyl- 
glucosazone are thrown down. These are bright yellow 
needle-shaped crystals, single or in sheaves or stars. 
When in small amounts they must be searched for mi- 
croscopically. 

Quantitative Estimation. — The urine used should be 
taken from that of the twenty-four hours. 

Five centigrammes of sugar will reduce ten cubic cen- 
timetres of Fehling's fluid prepared as above. In mak- 
ing the estimate, proceed as follows: 

Ten cubic centimetres of the fluid are diluted with 
forty cubic centimetres of water, and placed in a floren- 
tine flask. A burette is filled with some of the urine, 
diluted with nine parts of water. The flask is put upon 
a tripod, and the fluid boiled. A little of the urine is 
added from time to time until the light blue color is lost. 
It is well to remove the flask after each addition of 
urine, and examine it. Just when the color disappears 
is a nice point to decide, and upon it depends the accu- 
racy of the test. The amount of diluted urine used is 
now read off. Suppose that the quantity is ten cubic 
centimetres. Now, if ten cubic centimetres of dilute 
urine contain 0.05 gramme of sugar, then one hundred 
cubic centimetres would contain 0.5 gramme, and one 
hundred cubic centimetres of the undiluted urine would 
contain five grammes, or five per cent of sugar. 

Purely' s Method. — This method has the advantages 
over Fehling's that no precipitate is formed, the end 
reaction is a colorless fluid, and the standard solution is 
permanent. Dissolve 4.752 grammes of pure cupric 



204 PHYSICAL DIAGNOSIS. 

sulphate and thirty-eight cubic centimetres of glycerin 
in two hundred cubic centimetres of distilled water with 
the aid of gentle heat; dissolve 23.50 grammes of potas- 
sium hydroxide in two hundred cubic centimetres of dis- 
tilled water, mix the solutions, and when cool add three 
hundred and fifty cubic centimetres of strong ammonia 
(U. S. Pharmacopoeia, specific gravity 0.9). Bring the 
solution up to one thousand cubic centimetres with dis- 
tilled water. Thirty-five cubic centimetres of this solu- 
tion correspond to 0.02 gramme of glucose. Measure ac- 
curately thirty-five cubic centimetres of the solution into 
a flask of one hundred and fifty to two hundred cubic 
centimetre capacity, and dilute with distilled water till the 
flask is half filled, then boil. Run the urine slowly from 
a burette into the boiling fluid, drop by drop, till the 
color begins to fade; then still more slowly, three to five 
seconds elapsing after each drop, until the blue color 
completely disappears and leaves the test solution per- 
fectly transparent and colorless. The amount of urine 
used contains 0.02 gramme of sugar. The best results 
are obtained by first diluting the urine before titration. 
Any dilution may be employed, and the result multiplied 
by the number of dilutions. 

In diabetes mellitus the percentage of sugar varies 
from a minimum of one-half per cent to a maximum 
of ten per cent. 

The fermentation saccharometer of Max Einhorn gives 
approximately the amount of sugar contained in a 
specimen of urine. It is based on the principle that, in 
alcoholic fermentation, for a given quantity of sugar 
so much carbon dioxide is evolved. The apparatus is 
shown in the accompanying cut. The method of using 



SUGAR. 



205 



it is as follows : Shake one gramme of commercial com- 
pressed yeast with ten cubic centimetres of the urine to 
be examined in a test tube, and fill the long arm of the 
instrument with the mixture. Set it aside for twenty- 
four hours in a room of ordinary temperature. As the 
carbon dioxide is given off it rises to the top and dis- 
places the urine, giving the percentage of sugar present. 
If the urine contains more than one per cent of sugar, 



if i 




Fig. 25.— Saccharometer. 



it must be diluted with water and again tested. The 
degree of dilution must be taken into account in making 
the reading. 

In applying this test, it is well to perform a control 
experiment with normal urine in order to prove the 
purity of the yeast. Fill a test tube with the urine and 
thoroughly mix a little of the yeast with it. Then 
invert the tube in a tumbler containing some of the 
same urine. If the yeast is pure, after twenty-four 



206 PHYSICAL DIAGNOSIS. 

hours there will be no accumulation of gas at the top of 
the tube, but perhaps a small bubble of air may be seen. 

Clinical Significance. — The presence of sugar in the 
urine indicates that there is an excess in the blood. It 
may occur temporarily and in small quantity (glyco- 
suria), or continually and in large quantity (diabetes 
mellitus. ) Persons who confine themselves largely to a 
carbohydrate diet may occasionally have sugar in their 
urine. It is almost constantly present during convales- 
cence from acute infectious diseases, such as typhus 
fever, diphtheria, pneumonia, etc. 

In lesions of certain parts of the central nervous sys- 
tem, sugar is found in the urine : injury to the medulla 
gives rise to a diabetes which may last for a considerable 
time. 

Glycosuria follows poisoning by carbon dioxide and 
the administration of ether or chloroform. Gouty pa- 
tients are subject to glycosuria at intervals. 



When bile is present in the blood it is excreted by 
the kidneys. It imparts a dark olive-green tint to the 
urine. Gmelin's test for the bile pigments consists in 
placing a drop of the urine on a white surface and a 
drop of fuming nitric acid alongside of it. As the two 
come in contact a beautiful play of colors is observed, 
commencing with green and blue, changing rapidly to 
violet and red, and finally to yellow or brown. 

Rosin's Modification of Smith's Test. — Five to ten 
cubic centimetres of urine are placed in a test tube, and 
two to three cubic centimetres of tincture of iodine 
diluted with alcohol (1:10) are run down the side of 



BLOOD. 207 

the tube so as to form a layer over the urine. If bili- 
rubin be present a distinct emerald-green ring appears 
at the point of contact. This test is extremely delicate. 

The presence of biliary acids can be demonstrated by 
Pettenkofer's test. Add a few drops of a weak solution 
of cane sugar to a little of the urine in a porcelain cap- 
sule. Place the capsule in cold water. Now add an 
excess of concentrated sulphuric acid, drop by drop, tak- 
ing care that the temperature is not raised above 70° C. 
A beautiful violet color indicates the presence of the 
bile acids. 

In cases of jaundice the bile coloring matter or the 
biliary acids are present in the urine in greater or less 
abundance. 

BLOOD. 

The blood cells may be present in the urine (haematu- 
ria), or only their coloring matter in solution (haemoglo- 
binuria). Blood may be intimately blended with the 
urine, and form little or no sediment. Urine contain- 
ing blood is generally alkaline in reaction, and of a light 
smoky to a deep-red color. The most reliable test for 
blood is that furnished by the spectroscope. (For the 
microscopical examination, see lesson on Clinical Micro- 
scopy.) Haemoglobin produces two characteristic ab- 
sorption bands in the yellow and green between the lines 
D and E. If it is reduced haemoglobin, only one broad 
band is seen. 

The guaiacum test consists in adding a drop of the 
tincture of guaiacum and a few drops of ozonic ether 
to a little of the urine in a test tube. The mixture is 
shaken, and then the ether allowed to collect at the top. 
If blood be present, the ether will have a blue color. 



208 PHYSICAL DIAGNOSIS. 

The test cannot be relied upon in the presence of saliva 
or the salts of iodine, or unless the tincture is freshly 
prepared. 

Blood occurs in the urine after injury to any part of 
the genito-urinary tract, in acute congestion and inflam- 
mation of the kidneys, as a result of poisoning by car- 
bolic acid, in cancer of the bladder, and in acute infec- 
tious diseases, such as small-pox, yellow fever, etc. It 
is present in malaria, scurvy, purpura, and haemophilia. 

PUS. 

Pus in the urine (pyuria) forms a heavy white or yel- 
lowish sediment, and the liquid above is generally tur- 
bid. The urine is alkaline in reaction, except in cases 
of pyelitis and pyelonephritis, where it is acid. Owing 
to the alkalinity, the phosphates are quickly thrown 
down. It is common to find the earthy phosphates and 
crystals of ammonio-magnesium phosphate associated 
with the pus cells (see page 221), in which case the urine 
has an ammoniacal odor. 

When sodium hydrate is added to a deposit of pus, a 
thick, gelatinous mass is formed. But the test is not 
accurate. The presence of pus cells should always be 
demonstrated by a microscopical examination. 

In cystitis an abundance of mucus is usually mixed 
with the pus. 

Pyuria indicates suppuration somewhere in the genito- 
urinary tract. It occurs in pyelonephritis, pyelitis, in 
cystitis, and in gonorrhoea. Leucorrhceal discharges 
often contaminate urine. If an abscess opens into the 
urinary passages, pus suddenly appears in the urine in 
large quantity, and after a few days diminishes in 
amount or ceases altogether. 



CLINICAL MICROSCOPY. 



LESSOR XVIII. 

CLINICAL MICROSCOPY — BLOOD, SPUTUM, URINE, VOMIT, 

PIECES. 

Examination of the Blood. 

For clinical purposes the microscopical examination of 
the blood is restricted to determining the number and 
condition of its cellular elements, their haemoglobin con- 
tent, the reaction of the serum on certain bacteria, and to 
searching for pathogenic bacteria and animal parasites. 
To obtain a specimen of blood for examination, the tip of 
the finger, or, better, the edge of the lobe of the ear, after 
being thoroughly cleansed, is pricked with a triangular- 
pointed needle, a slide is lightly touched to the apex of the 
drop of blood — which is allowed to run out, not pressed 
out — a cover glass is immediately placed over the drop, 
and slight pressure made so as to have a thin layer for 
examination. If the specimen cannot be examined im- 
mediately after its removal, a small amount of melted 
paraffin or flexible collodion, run around the edge of the 
cover glass, will keep the blood unchanged for several 
days. To prepare a dried specimen, instead of covering 
with a cover glass, the end of another slide is lightly 
drawn across the first one, spreading out the drop in a 
thin layer, which is allowed to dry spontaneously. For 
cover-glass specimens, one cover glass is touched to the 
apex of the drop and another cover glass is laid on the 
first at such an angle that the corners do not coincide. 



212 



PHYSICAL DIAGNOSIS. 



The two cover slips are then drawn apart in the same 
plane, not lifted apart. In a specimen so prepared the 
corpuscles may lose their true form. These artefact dis- 
tortions, however, all point in the same direction, which 
differentiates them from pathological malformations. 
When normal blood is examined under the microscope, 
three varieties of cells are noted. 

Bed Blood Corpuscles (Fig. 26). — These appear as 




Fig. 26.— Cellular Elements of Human Blood. A, red blood cells forming rouleaux; 
B, red blood cells crenated ; D and E, rod blood cells having absorbed water; F and G, 
red blood cells with surface in focus ; H, white blood cells. 



flattened, bi-concave discs with an average diameter of 
0.0075 millimetre. Between 6 p- and 9 p is within normal 
limits. When the centre of the cell is in focus, the 
outer rim appears dark ; when the edge is in focus, then 
the centre appears dark. The cells show a tendency to 
adhere to each other, forming rouleaux or coin heaps. 



BLOOD. 213 

After exposure to the air for a short time they lose 
their normal smooth contour, and the periphery becomes 
uneven or crenated. 

Blood Plates. — These are small, colorless, ovoid 
bodies, about one-quarter or one-half the size of a red 
blood corpuscle. They are usually seen cohering to- 
gether in masses. The number of blood plates under 
normal conditions is given as from 400,000 to 700,000 
per cubic millimetre. 

White Corpuscles or Leucocytes (Fig. 26). — 
These appear as transparent cells with a granular pro- 
toplasm. They are mono- or multinucleated. Their size 
varies from that of the red blood corpuscle to twice its 
size. The classification, at present, of the various kinds 
of leucocytes depends on the character of their nuclei, 
the reaction of their protoplasm to staining agents, and 
the place of their origin in the body. The aniline dyes 
used for staining are chemically basic or acid, or a com- 
bination of the two forming a neutral compound. The 
basic dyes, such as hematoxylin, methylene blue, etc., 
have a selective action on the acid principles of the cells, 
while the acid dyes, such as eosin and fuchsin, unite 
with the basic principles. There are thus basophils and 
acidophils granules in the leucocytes, while a compound 
of a basic and acid dye unites with certain elements in 
the cells which are called neutrophile. The leucocytes 
of normal blood are described as follows : (1) Small mono- 
nuclear leucocyte or small lymphocyte. These, supposed 
to arise in the lymphatic tissue, have a single compact 
nucleus and basophile granules, with but a thin layer of 
protoplasm surrounding the nucleus. (2) The large mono- 
nuclear leucocyte, with a large vesicular nucleus and 



214 PHYSICAL DIAGNOSIS. 

basophile reticulum. Their nuclei are oval or elliptical 
in shape, and are surrounded by a larger zone of cell pro- 
toplasm which is apparently non -granular. At times the 
nuclei appear bent like a horseshoe, or indented ; they are 
then called transitional forms. (3) The polynuclear or 
polymorphonuclear neutrophile leucocyte, with a nucleus 
of two or more lobes united by delicate threads, having 
the appearance of several nuclei, and with many neutro- 
phile granules. (4) The eosinophile leucocyte, with a nu- 
cleus of several separated lobes and with many eosino- 
phile granules. 

Two other forms of leucocytes appear in pathological 
blood which are not present under normal conditions: 
(1) Myelocytes, mononuclear cells with neutrophile or 
eosinophile granules. They are so named because they 
are probably derived exclusively from the bone marrow. 
They occur chiefly in leucaemia. (2) Mast cells. These 
are mono- or polynuclear with large basophile granules 
which must be demonstrated with a special stain (Ehr- 
lich's dahlia). They occur almost exclusively in mye- 
logenous leucaemia. The normal number of leucocytes 
varies, according to Cabot, from 3,000 to 10,500, prob- 
ably averaging from 5,000 to 7,000. The proportion of 
the different varieties is given as follows : 

Small mononuclear leucocytes, 20-30 per cent. 

Large " " 4-8 " 

Polymorphonuclear " 60-75 " 

Eosinophile " J-4 " 

Changes in Numbers of Eed Blood Corpuscles. — 
Normal blood contains from 4,500,000 to 5,000,000 red 
blood corpuscles to the cubic millimetre, at sea level, 



BLOOD. 



215 



women having normally a smaller number than men. 
This number is frequently surpassed in vigorous, healthy 
persons; 6,000,000 is not infrequent in healthy young 
men. Altitude above sea level raises the count in direct 
ratio to the height attained. Concentration of the blood 
from any cause, such as profuse sweating, temporarily 
raises the count of red cells. In the new-born for the 
first ten days of life the number of red cells is very high, 
7, 000, 000-8, 800, 000. In diseased conditions the number 
may fall to 2,000,000, 
and in extreme cases to 
less than 500,000. Mark- 
ed decrease in number is 
readily detected with the 
aid of the microscope; 
the field is more trans- 
parent, the color of the 
corpuscles is paler, 1 they 
show their bi-concave 
form less characteristi- 
cally, and the rouleaux 
are not as marked. The 
above appearances are 
generally sufficient for 
rough diagnostic pur- 
poses. When the exact 
number is desired, the 
Thoma - Zeiss or some 
other counting apparatus 

. t Fig. 27.— Thoma-Zeiss Pipettes. .4, For red 

IS required.. corpuscles; B, for white corpuscles. 



B 



1 Oligocythemia is usually associated with deficiency of coloring 
matter. 



216 PHYSICAL DIAGNOSIS. 

The Thoma-Zeiss instrument consists of a pipette by 
means of which a measured amount of blood is diluted 
in a known proportion (see Fig. 27). The tube of the 
pipette is graduated in such a manner that when it is 
filled with blood up to the mark 1, and then with a 
diluting fluid up to the mark 101, the dilution of the 
blood is 1: 100. If the pipette is filled to the mark 0.5 
the dilution of the blood is 1 : 200. Within the bulb of 
the pipette there is a glass ball to aid in mixing the 
blood. The diluting fluids used are (1) a six-per-cent. 
solution of common salt deeply tinged with gentian 
violet; (2) Toisson's solution, which also stains the 
white cells so that they can be easily distinguished from 
the red. The formula is as follows : 

Methyl violet 5 B 025 gm. 

Sodium chloride 1.000 " 

Sodium sulphate 8.000 " 

Neutral glycerin 30.000 cm. 

Distilled water 160.000 " 

(3) Gowers' solution: 

Sodii sulphatis gr. 112 

Acidi acetici 3 i. 

Aquse § iv. 

The counting chamber consists of a large glass slide 
with a central excavation. In this excavation a shelf 
has been cemented, and on its surface a square millime- 
tre is ruled off and divided by fine lines into four hun- 
dred squares. Every fifth square is divided by an addi- 
tional line. The surface of the shelf is 0.1 millimetre 
below the level of the surface of the slide. If therefore 



BLOOD. 



217 



a drop of the diluted blood be placed on the shelf and 
covered with a cover glass the number of cells seen in 
each small square will be the number contained in T J-g- 
X To — 4 (/o o cubic millimetre. The method of procedure 




Fig. 28.— Thoma-Zeiss Counting Slide. A, Ruled disc; B, cover-glass; C, moat. 

is described by Dr. Ewing as follows : The cleaned fin- 
ger tip or ear is punctured and a drop of blood is allowed 
to flow. The pipette is filled to the mark (1) or (0.5) ; if 
the blood be drawn a little above the mark gentle tap- 
ping on the point will bring it down to the mark. The tip 
is then cleaned of adherent blood. The mixing fluid is 
then quickly drawn into the pipette to the mark 101, and 
thoroughly shaken. The counting-chamber and cover 



0100mm. 
400 <p. 




C.Zeiss 
Jena 



Fig. 29.— Thoma-Zeiss Counting Slide. A, Ruled disc. 



glass having been thoroughly cleaned, two drops of the 
diluted fluid are expelled from the pipette, and a small 
drop is then placed on the centre of the shelf. As 
quickly as possible the cover glass is adjusted and firmly 



218 



PHYSICAL DIAGNOSIS. 



pressed down. If Newton's color-rings appear at the 
corners of the cover glass the preparation is successful. 
Dust particles may prevent intimate contact of the slide 
and cover glass and the formation of these rings, and must 
in every case be avoided. The rapid and successful ad- 
justment of the cover glass is the most important detail 
in the process of counting red cells. The size of the 

drop to be deposited 
on the shelf can only 
be learned by experi- 
ence. When the cover 
glass is in place the 
blood must at least 
cover all, or nearly all, 
the shelf. It may 
project into the moat, 
but if it runs out 
underneath the cover 
glass the specimen 
must be discarded. 
The preparation ap- 
pearing thus far successful, it is examined in the light 
to see that the red cells are evenly distributed. If the 
cover glass has not been rapidly adjusted it will be 
found that the central portions of the blood contain more 
cells than the peripheral, in which case the specimen 
must be rejected. After the cells have settled for a 
moment, counting may proceed, using a mechanical 
stage and Leitz No. 7 lens. One hundred small squares 
at least must be counted over. To avoid counting the 
same cells twice it is customary to include in any square 
those cells lying on the lines below and to the right of 



o° 

c 





O 




1 ° 

1 o° 


K o 

jo o 


o o 
o o 


o o 
o 


c 


o 


o 


Q O O 


o 


o r 


ooo 


, °o 


O O 


o o 


c 


o 


o 


o u 


O 


o 

, : 


o o 


o o 


-Q-o 


o 





o 


o o 
o 


o°°° 




o 
o 


O 



° o 
O o 


oo 

o ° 


O 

°o° 


O c 
o c 


Q 





o 
o 


O O 

o o 


o o 




o 



o 
o 


Oo 

o o 

O Oo 


p ° ° 

o o 


o " 
° Q 

o 


oc 
oo 
o 
o o 


o 

oc 


o 
o 

o 


o °° 

o o 
o o 


ooo 

O o 

o 


o 

o 


o 
o 


oo 

) 00 O 


O o 

o o 


o 
° o 

00 


o°o 




o 
o 


o 
o 
c 


o 


oo 


o 


o 


0°OC 
oo n 


°o 
> °o 


O 0°o 

o o 

Oo 


O O 
O O o 
Oo 


c 

o 

o 


c 




o o 

o ° 
o° 


O o 


3 


) o 


o 


o°° 


°o < 


, o 





.- 


o 





, 




> °o 


o 
°. o 


o o 


o°° 


o J 


° 


w o 


° 

°l 








o 


°o° 
O q 


O o 

o O 


°0° 

o° 

o 


° °o 

o o 


D 

< 


^0 


o 



Fig. 30.— Field of Thirty-Six Squares on Ruled 
Disc of Thoma-Zeiss Counter Covered with 
Normal Blood Diluted Two Hundred Times. 



BLOOD. 219 

the square, omitting such as lie on the lines above and 
to the left of the square. 

Computation. — Having counted all the cells in one 
hundred small squares, the number per cubic millimetre 
may be estimated as follows : One hundred small squares 
comprise an area of J-g-jj- square millimetre, or a cubic 
contents of J^-X iV (depth) = ■£$ cubic millimetre. The 
dilution of the blood being 1:100, the number of cells 
counted is therefore to be multiplied by 40x100 =4,000. 
If 400 small squares are counted for complete accuracy, 
the multiplier is 1,000. 

Cleaning the Instrument. — After every use of the 
pipette it is absolutely essential that both chamber and 
tube be thoroughly and properly cleaned and dried. 
The counting chamber is to be wiped with a cloth moist- 
ened with water. Alcohol and ether dissolve the cement 
under the shelf. 

The mixing pipette is first emptied of blood, the last 
particles of which are to be dissolved by refilling with 
water. The bulb is then filled with alcohol and then 
with ether, and after this fluid has been expelled the tube 
must be thoroughly dried before using again (blowing 
dry air from a rubber bulb will soon dry it). Minute 
particles of water remaining in the tube cause the partial 
or complete solution of red cells in the subsequent speci- 
men, and the appearance of faint "shadow corpuscles." 

Enumeration of Leucocytes. 

Leucocytes are best counted in the same specimen and 
chamber with the red cells. A special chamber has been 
constructed for this purpose, in which nine square milli- 
metres can readily be recognized by examining the 



220 



PHYSICAL DIAGNOSIS. 



chamber with the low power of the microscope. In 
order to enumerate a sufficient number of leucocytes for 
accurate results, it is necessary to count all the white 
cells appearing in three, six, or nine square millimetres, 
according to their abundance. Only eight to ten leuco- 
cytes are found in one cubic millimetre of diluted nor- 
mal blood, but at least fifty must be counted to secure 



a 



'! 






mi ii iiiiiiiii 














iiil 








1 






m 








ll 





















ISH 




























lllilllllllillll 









Fig. 31.— Modified Ruling of Thoma-Zeiss Counting-chamber. 



any reliable indication of their numbers, while at least 
one hundred or more must be counted when minor vari- 
ations in number are being followed. 

For the purpose of counting over this larger area, a 
mechanical stage is almost essential. 

The leucocytes are readily identified in salt solution, 
after a little practice, by their refractive appearance, 
and usually also from their bluish stain from gentian 
violet. The small lymphocytes are the only ones that 
are liable to be overlooked with ordinary care. 



WHITE BLOOD CORPUSCLES. 221 

Computation. — If fifty-four leucocytes are found in 
six square millimetres the average is nine per square 
millimetre, or (9X1,000) nine thousand per cubic milli- 
metre. 

Increase in the Number of White Blood Corpus- 
cles (Leucocytosis) . — The proportion of white to red 
corpuscles in the blood varies from 1 : 400-700. In dis- 
eased conditions this ratio is often diminished ; in leukae- 
mia it may even become 1:1. The varying ratio be- 
tween the number of red and white cells is not the 
essential point in leucocytosis, but it is the actual in- 
crease in white cells above the normal for the individual, 
the kind of leucocytes present, and their ratio to the total 
number of leucocytes. All leucocytoses are not evi- 
dences of disease, as there are physiological leucocytoses, 
viz. : Leucocytosis of the new-born, of digestion, of 
pregnancy, post partum, and after violent exercise, 
massage, and cold baths. Those of the new-born and 
post partum may be as high as 36,000 per cubic milli- 
metre, while those of the other physiological conditions 
do not usually go above 13,000-15,000. The relative 
percentage of the different kinds of leucocytes remains 
unchanged. 

In considering the leucocytosis of disease several fac- 
tors must be taken into consideration. Certain diseases 
do not cause a leucocytosis at all, and in the diseases in 
which it is present it varies in intensity in ratio to the 
severity of the infection and the resistance of the indi- 
vidual affected. A mild infection against a good resist- 
ance gives but a slight leucocytosis. A more severe 
infection against a good resistance gives a marked leu- 
cocytosis. An overwhelming infection, breaking down 



222 PHYSICAL DIAGNOSIS. 

all resistance, gives no leucocytosis. The absence of 
leucocytosis, therefore, may indicate a very favorable or 
a fatal prognosis, while the presence of a marked leuco- 
cytosis indicates a strong reaction against an infection, 
but does not indicate the final result. Leucocytosis is 
regularly absent in typhoid fever, malaria, in most cases 
of grippe, measles, and tuberculosis (except in some 
cases of tubercular meningitis and peritonitis, and pul- 
monary tuberculosis with mixed infection). It is pres- 
ent in the other acute infectious fevers and in all pysemie 
and septicemic conditions, in the secondary stage of 
syphilis, in carcinoma and sarcoma (some cases), actino- 
mycosis, trichinosis, and following the ingestion of cer- 
tain substances as salicylates, in illuminating gas poi- 
soning, during and after etherization, and after severe 
hemorrhages. In the majority of these diseases it is the 
polymorphonuclear leucocytes which are increased, but 
in trichinosis the eosinophils are the ones affected. The 
largest leucocytosis is present in the bubonic plague, in 
which 200,000 per cubic millimetre have been seen. 
Next to this pneumonia and sepsis show the greatest 
number. 

The blood in leukaemia is peculiar to the disease. 
While the ratio of red to white cells is much diminished, 
becoming as low as 1:1, or even, as in some cases on 
record, the white cells have been actually more numer- 
ous than the red, the characteristic features of leukaemic 
blood are the presence of abnormal cells and the abnor- 
mal proportions in which the leucocytes occur. In the 
majority of cases there are two distinct types, splenic- 
myelogenous or myelocythaemia, with great hypertrophy 
of the spleen and marrow changes, with but little or no 



WHITE BLOOD CORPUSCLES. 



223 



involvement of other lymphatic tissues, and lymphatic 
leukaemia or lymphaemia with some group of lymphatic 
glands enlarged. Myelocythaemia usually runs a chronic 
course, while lymphaemia is more often an acute disease. 
The characteristics of myelocythaemia are : a moderate 
decrease in the red cells, usually to about 3,000,000 per 
cubic centimetre ; the haemoglobin a little more than pro- 




FlG. 



-Blood from Case of Leucocythaemia. A A, white corpuscles; B B, red blood 
corpuscles. X 300. 



portionately decreased ; nucleated red cells, both normo- 
blasts and megaloblasts, are very numerous (see Blood 
of Anaemia for a description of these cells), the former 
usually predominating. The total number of white 
cells averages about 450,000 per cubic millimetre. Mye- 
locytes are present in large numbers and basophile cells 
are also numerous. The percentage of polymorphonu- 
clear neutrophiles and small and large mononuclear cells 
is diminished from the normal, while that of the eosino- 
philes is often slightly increased. Of course the actual 



224 PHYSICAL DIAGNOSIS. 

number of all leucocytes is enormously increased, but 
the percentage present of each variety varies greatly 
from the normal. 

In acute lymphaemia the red cells are much diminished, 
with a rapidly progressing ansemia. The nucleated red 
cells may be as abundant as in myelocythaemia, though 
usually they are not so numerous. The actual number 
of leucocytes is not, as a rule, so great as in myelocythse- 
mia, and the lymphocytes form about ninety per cent of 
all leucocytes present. The large mononuclear forms 
usually predominate. The polymorphonuclear neutro- 
phils and eosinophiles are few in number. 

In chronic lymphasmia the red cells are not so much 
diminished as in the acute form, and the nucleated 
forms are not common. The small lymphocytes are the 
predominating form of leucocytes. As in acute lymph- 
aemia, they form over ninety per cent of the total number. 
The myelocytes and eosinophiles are scanty, and the 
neutrophiles are present in but a small percentage. 

In estimating the percentages of leucocytes a stained 
preparation must be used. The specimen of blood must 
be prepared in a thin layer, as already described in the 
preparation of a dried specimen. After the specimen 
has dried spontaneously it is hardened by heat or im- 
mersion in equal parts of absolute alcohol and ether. If 
the leucocytes are to be studied, heat fixation is the best. 
The specimens should be heated in a hot-air oven to 
140°-155° C, and as soon as the temperature reaches 
the required point the specimens should be taken out 
and allowed to cool. If the red cells are the ones to be 
studied for malarial organisms or nucleated red corpus- 
cles, the alcohol and ether method is sufficient, and the 



RED BLOOD CORPUSCLES. 225 

specimens should be immersed for one-half hour, though 
a twenty-four-hour immersion is much better. The 
best stain is Ehrlich's triacid mixture It is made as 
follows (Cabot) : 

Saturated watery solution of orange G . . . 6 c.c 
" " " acid fuchsin. . 4 " 

Add to these, a few drops at a time, shaking between 
each addition : 

Saturated watery solution of methyl 

green. . . 6.6 c.c. 

Then add : 

Glycerin 5 c.c. 

Absolute alcohol 10 " 

Water 15 " 

Shake thoroughly for a few minutes and allow it to 
stand for twenty-four hours. Do not filter. 

A drop of this stain is spread over the specimen and 
allowed to stain for at least three minutes. It can be 
left longer if desired, as it will not overstain. It is then 
washed off with water, the specimen dried between filter 
paper and mounted with balsam, and is then ready for 
examination. In estimating the differential percent- 
ages of leucocytes, from five hundred to one thousand 
leucocytes must be counted, and the percentage of each 
form present must be reckoned. 

Changes in Size, Form, and Color of Eed Blood 
Corpuscles. — At times the blood contains cells that are 
smaller than the normal red blood corpuscles, but which 
have the same shape and contain haemoglobin. These 
cells are called microcytes, and the condition micro- 
cythcemia. It occurs in all forms of anaemia, and has no 
diagnostic significance. 

15 



226 PHYSICAL DIAGNOSIS. 

Colored corpuscles that are larger than normal (met- 
er ocytes) are also found, and, while they may be present 
in all anaemias, they are most common in the pernicious 
type. 

Closely associated with variation in size is that of 
form. The red blood corpuscle may assume a variety 
of shapes, as club, dumb-bell, anvil, flask, etc., when 
they are called poikilocytes (Fig. 33), and the condition 
poikilocytosis. These cells are found in varying num- 




Fig. 33.— Poikilo, Macro-, and Microcytes (d, b, c). a, normal red blood cell; e. 
broken-down red blood cell; /, nucleated red blood cell (marked anaemia). (After 
Quincke.) 

bers in all anaemic conditions, but are most marked in 
pernicious anaemia. These degenerations are called ne- 
crobiosis. Another evidence of necrobiosis is the change 
in color certain red cells take with the triacid stains. 
Instead of the orange color they are brownish, purple, 
or gray. This is called polychromatophilia. 

Besides these necrobiotic changes in anaemia we find 
three forms of nucleated red cells : normoblasts, megalo- 
blasts, and microblasts. The normoblasts are found in 
the bone marrow of healthy individuals. They are of 
the same size and color as a normal red cell, but contain 



RED BLOOD CORPUSCLES. 



227 



a round nucleus, which usually lies to one side in the cell 
and equals about one-half the diameter of the whole cell. 
The nucleus may project over the edge of the corpuscle 
or even half out of it. With Ehrlich's tri-color stain 
the nucleus is stained blue-black or light blue-gray with 
a dark blue rim. Occasionally the nucleus is not single 
and round, but may be double or many-shaped. 

The megaloblast is a very large cell from 11 to 20/* in 
diameter. It frequently shows polychromatophilia. Its 
large nucleus fills most of the cell, and stains pale green 
with Ehrlich's tri-color stain. There are often purplish 
granules scattered through the nucleus. 

Microblasts are rarer than either of the other nucleated 




Fig. 34.— Fleischl's Haemometer. a, Partition into which the blood is put; a', par- 
tition into which water is put; G, mixing cell; K, K, colored glass slip; P, P, metal 
frame on which scale is marked; R, S, reflector; T, screw which moves the frame, P, P. 



red cells. The cell body is smaller than the normal red 
cell and contains a nucleus like that of the normoblast. 
As the color of the red blood corpuscles depends upon 



228 PHYSICAL DIAGNOSIS. 

the amount of coloring matter they contain, a pale color 
of the blood may be due to a deficiency of haemoglobin, 
as well as to a diminution in the number of cells. Both 
conditions may be appreciated under the microscope with 
little practice. To estimate accurately the amount of 
haemoglobin in the blood, Yon MeischPs haemometer or 
Henocque's haematoscope is required. 

The method of estimating the haemoglobin with Von 
Fleischl's instrument consists in comparing a certain 
amount of blood dissolved in distilled water with the 
colors of a graduated glass wedge. A metallic cell di- 
vided into two compartments is placed on the stand of 
the instrument in such a manner that the compartment 
containing clear water rests over the colored glass 
wedge, while that containing the blood rests so that 
the light penetrates directly. The wedge is then moved 
up or down the scale till the colors in the two compart- 
ments seem to correspond. The number is then read off 
on the scale, which gives the percentage of haemoglobin. 
The scale reads from zero to 120. The color of normal 
blood for men is 100, for women 80-90. The method of 
procedure is as follows: One compartment of the me- 
tallic cell is partially filled with water, and one of the 
capillary tubes in metal handles accompanying the in- 
strument is touched to the drop of blood flowing from 
the punctured ear or finger, when it will fill instantly 
with blood ; any blood on the outside of the tube is 
rapidly wiped off, and the tube i*s quickly put in the 
water in the cell and rattled to and fro. The capillary 
tube is then washed out by forcing water through it 
from a medicine dropper. Both sides of the cell are 
filled up with water, using the medicine dropper and 



BLOOD CHANGES. 229 

stirring the blood mixture with the metal handle of the 
pipette. Great care must be taken that the fluid in one 
side does not run into the other. The examination is 
made in a dark room by yellow candle-light or lamp- 
light and the colors seen in the two cells are matched by 
moving the glass wedge to and fro. 

It is important to see that the glass pipette is clean 
and dry before using ; passing a thread wet with alcohol 
and ether through it will clean it. When filled the tube 
must be level full, with neither a convex nor concave 
meniscus. To prevent oxidation a glass cover may be 
placed over the filled cell. Care must be used not to 
enclose air bubbles or expel any of the blood solution. 
Do not sit facing the light, but always sideways to it. 
Use as little light as possible. A yellow or black paper 
tube fitted over the cell is of great assistance. Alter- 
nate the eyes, and rest them from time to time. As 
Cabot points out, sudden color changes affect the refcina 
more than gradual ones. The thumb-screw should be 
moved with quick, short turns rather than slowly and 
gradually. 

Clinical Significance of Blood Changes. — The 
diagnostic value of changes in the number of white blood 
corpuscles has already been noted. 

In simple anaemia, due to hemorrhage, or dependent 
upon diseased conditions associated with diminution in 
the number of red blood corpuscles, there is a corre- 
sponding decrease in the amount of haemoglobin. In 
the severer forms there is necrobiosis of the red cells and 
normoblasts, and often a leucocytosis. 

In chlorosis, although the number of red blood cor- 
puscles is not notably reduced, usually not below 4,000,- 



230 



PHYSICAL DIAGNOSIS. 




Fig. 35. —Normal Blood. Magnified 350 diameters. 



Fig. 36. —Pernicious Anaemia, Magnified 350 diameters. Note the relatively large 
size and well-stained centers of the cells. 



BLOOD CHANGES. 



231 




Fig. 37. —Chlorosis. Magnified 350 diameters. Note small size and pale centers. 




Fig. 38.— Chronic Secondary Anaemia Due to Bleeding 
ters. Note the similarity of chlorotic blood (Fig. 37). 



Piles. Magnified 350 diame- 



232 PHYSICAL DIAGNOSIS. 

000, the loss of haemoglobin is excessive, and the indi- 
vidual cells appear pale and "washed out." Microcytes, 
macrocytes, and poikilocytes may be found in small 
number. Normoblasts are rare even in severe cases. 
Blood plaques are usually increased. There is not usu- 
ally a leucocytosis ; sometimes there is an increase of 
lymphocytes, and a few myelocytes have at times been 
observed. 

Pernicious anaemia is attended with a great diminu- 
tion in number of all the cellular elements. The red 
cells are diminished to about one million per cubic 
millimetre. The haemoglobin content of individual cells 
is often relatively high. There is an increase in average 
size of the red cells. Poikilocytosis aod polychromato- 
philia are common. Nucleated red cells are often abun- 
dant, and the megaloblasts are more numerous than 
the normoblasts. The white cells are diminished, and 
there is often a lymphocytosis with a small number of 
myelocytes. 

Free pigment, and white blood corpuscles containing 
pigment granules, are found in the melanaemia of ma- 
larial disease. 

Serum Diagnosis. — A few years ago Pfeiffer dis- 
covered that the serum of the blood of animals immun- 
ized against a given infection would cause a definite 
reaction when mixed with the culture of the germ 
causing the infection. Widal applied this clinically to 
typhoid fever. The reaction consists in the aggluti- 
nation of the scattered and actively motile bacilli into 
clumps of motionless bacilli, with the spaces between 
these clumps clear or nearly clear of bacteria. The 
methods of procedure are as follows: (1) After careful 



SERUM AND DRIED BLOOD. . 233 

disinfection of arm and syringe, about five cubic centi- 
metres of blood are drawn from a superficial vein, and 
immediately expelled into a sterile test-tube and set aside 
until the serum has separated from the blood clot. 
Eight drops of the serum are then placed in four cubic 
centimetres of neutral broth, and the mixture is inocu- 
lated with a loopful of a twenty-four-hour old bouillon 
culture pi typhoid culture. This culture is allowed to 
stand twenty-four hours at 37° C. At the end of this 
time, perhaps earlier, the culture will be clear, and there 
will be flakes of bacilli as a sediment at the bottom of 
the tube or adhering to the sides if the case be one of 
typhoid fever. Otherwise the broth will be evenly tur- 
bid and a true sediment does not occur. 

(2) Nine drops of culture are measured with a medi- 
cine dropper into a small test-tube, and then one drop of 
fresh blood from the punctured ear or finger is dropped 
from the same dropper into the test-tube. A loopful of 
this mixture is then examined on a cover-glass on a hol- 
low slide, or simply between cover-glass and slide, to see 
if a typical reaction occurs. This gives the usual 1 : 10 
dilution. 

"The following are the methods and technique recom- 
mended by the New York Health Department : l 

" Technique of Obtaining Serum and Dried Blood. 
— Blood may be easily obtained by pricking the tip of 
the finger or the ear. Two or three large drops should 
be collected on a glass slide and allowed to dry. Paper 
is not as good a receiver for the blood as glass, for the 
blood soaks more or less into it, and later, when it is 

1 Biggs and Park, The American Journal of the Medical Sciences, 
March. 1897. 



234 



PHYSICAL DIAGNOSIS. 



dissolved, some of the paper-fibre is apt to be rubbed off 
with it. 

" In preparing the specimen for examination the dried 
blood is brought into solution by mixing it with about 
five times the quantity of water. Then a drop of this 
decidedly reddish mixture is placed on a cover-glass and 




Fig. 39.— Pure Culture. 




Fig. 40. —Partial Reaction. 



Fig. 41.— Typical Clumping. 



to it is added a drop of a fifteen- to twenty-hour bouillon 
culture of the typhoid bacillus. The two drops, after 
being mixed, should have a faint reddish tinge. The 
cover-glass, with the mixture on the surface, is inverted 
over a hollow slide (the edges about the concavity hav- 
ing been smeared with oil or fluid vaseline so as to make 



PSEUDO-REACTIONS WITH DRIED BLOOD. 235 

a closed chamber) and the hanging drop then examined 
under the microscope (preferably by gaslight), a high- 
power dry lens (about -§- inch) being used. 

"If the reaction takes place rapidly, the first glance 
through the microscope reveals the completed reaction, 
all the bacilli being in loose clumps and nearly or alto- 
gether motionless. Between the clumps are clear spaces 
containing few or no isolated bacilli. 

" If the reaction is a little less complete, a few bacilli 
may be found moving slowly between the clumps, in an 
aimless way, while others attached to the clumps by one 
end are apparently trying to pull away, much as a fly 
caught on fly-paper struggles for freedom. 

"If the agglutinating substances are still less abun- 
dant, the reaction may be watched through the whole 
course of its development. Immediately after mixing 
the blood and culture together it will be noticed that 
many of the bacilli move more slowly than before the 
addition of the serum. Some of these soon cease all 
progressive movement, and it will be seen that they are 
gathering together in small groups of two or more, the 
individual bacilli being still somewhat separated from 
each other. Gradually they close up the spaces between 
them, and clumps are formed. According to the com- 
pleteness of the reaction, either all the bacilli may finally 
become clumped and immobilized or only a small portion 
of them, the rest remaining freely motile, and even 
those clumped may appear to be struggling for freedom. 
With blood containing a large amount of the aggluti- 
nating substances all gradations in the intensity of the 
reaction may be observed, from those shown in a marked 
and immediate reaction to those appearing in a late and 
indefinite one, by simply varying the proportion of blood 
added to the culture fluid. 

" Psendo -reactions with Dried Blood. — If too con- 
centrated a solution of dri,ed blood from a healthy person 
is employed, there will be an immobilization of the 



236 PHYSICAL DIAGNOSIS. 

bacilli, but no true clumping. This is sometimes mis- 
taken for a reaction. Again, dissolved blood always 
shows a varying amount of detritus, partly in the form 
of fibrinous clumps, and prolonged microscopical exam- 
ination of the mixture of dissolved blood with a culture 
fluid shows that the bacilli often become more or less 
entangled in these clumps, and in the course of one-half 
to one hour very few isolated motile bacteria are seen. 
The fibrinous clumps, especially if examined with a poor 
light, may be very easily mistaken for clumps of bacilli. 
This pseudo-reaction is regarded by many inexperienced 
observers as a true typhoid reaction, but it occurs as 
readily with non-typhoid as with typhoid blood. [An- 
other form of pseudo-reaction may occur in which there 
will be distinct clumping, the clumps, however, are not 
motionless, but there is a noticeable heaving of the 
clumps and a greater or smaller number of freely motile 
bacilli are seen moving between the clumps.] 

" The Use of Serum Obtained from Blisters or the 
Blood. — Fluid serum can be easily obtained in two 
ways : 1st. The serum may be obtained directly from the 
blood thus : the tip of the finger or ear is pricked with 
a lancet-shaped needle, and the blood as it issues is al- 
lowed to fill by gravity a capillary tube having a central 
bulb. The ends of the tube are then sealed by heat or 
wax, and as the blood clots a few drops of serum sepa- 
rate. This method of obtaining blood-serum has the 
advantage of rapidity; but also this disadvantage, 
namely, that the serum thus separated is apt to contain 
more or less blood-cells, which somewhat obscure the 
field when the liquid serum is immediately mixed with 
the culture, and which cause clumps of detritus (resem- 
bling, though less marked, those found with the dried 
blood), if the serum is allowed to dry. 2d. The serum 
may be obtained from a blister. In the examinations 
thus far made this has given, far more satisfactory re- 
sults. The method is as follows : a piece of cantharides 



SERUM AND DRIED BLOOD. 237 

plaster the size of a five-cent piece is applied to the skin 
at some spot on the chest or abdomen. A blister forms 
in from six to eighteen hours. This should be protected 
from injury by a vaccine shield or bunion plaster. The 
serum from the blister is collected in a capillary tube, 
the ends of which are then sealed. Several drops of the 
serum can be easily obtained from a blister so small that 
it is practically painless and harmless. The serum ob- 
tained is clear and admirably suited for the test. 

" The Advantages and Disadvantages of Serum and 
Dried Blood for the Serum Test. — The dried blood 
is easily and quickly obtained and does not deteriorate 
or become contaminated by bacterial growth. It is 
readily transported, and seems to be of nearly equal 
strength with the serum in its agglutinating properties. 
It must, however, in use, be diluted with at least five 
times its bulk of water, otherwise it is too viscid to be 
properly employed. The amount of dilution can only 
be determined roughly by the color of the resulting 
mixture, for it is impossible to estimate accurately the 
amount of dried blood from the size of the drop. 

" Serum, on the other hand, can be used in any dilu- 
tion desired, varying from a mixture which contains 
equal parts of serum and broth culture to that contain- 
ing 1 part of serum to 100 parts of culture. It can be 
measured roughly by the platinum loop, or more care- 
fully by a graduated capillary pipette. The disadvan- 
tages in the use of serum are entirely due to the slight 
difficulty in collecting and transporting it, and the delay 
in obtaining it when a blister is employed. If the serum 
is obtained from blood after clotting has occurred, a 
greater quantity of blood must be drawn than is necessary 
when the dried blood method is used. If it is obtained 
from a blister, a delay of eight to eighteen hours is re- 
quired . The transportation of the serum in capillary tubes 
presents no difficulties if tubes of sufficiently thick and 
tough glass are employed and a proper case is supplied/' 



238 PHYSICAL DIAGNOSIS. 

In testing any specimen of dried blood or serum with 
a dilution of 1 : 10 or 1 : 20, if a typical reaction does not 
occur in fifteen to twenty minutes the result should be 
considered as "no reaction." 

Clinical Significance of WidaVs Test. — When pres- 
ent the Widal test is one of the surest single symp- 
toms of typhoid fever. But as a few cases have been 
reported in which the blood of other diseases has given a 
reaction in 1 : 10 dilution, we must consider a 1:10 reac- 
tion as indicating that the case is probably one of ty- 
phoid. A 1 : 20 reaction, however, may be considered as 
indicating that the patient in all probability has had or 
has typhoid. Eeactions in dilutions of 1: -10-50-100 
may be considered as positive. The reaction appears in 
the majority of cases by the tenth day. It may appear 
as early as the third or fourth day, or as late as the 
thirty-fifth. It sometimes does not appear until during 
convalescence or not at all during the attack, but does 
appear during a relapse. In from two to five per cent 
of all cases it does not appear at any time. The blood 
may retain the power of giving the reaction for weeks, 
months, or even years after recovery from typhoid. The 
presence of the Widal test may be positive proof of 
typhoid, but its absence in any given case at any time of 
the disease does not disprove typhoid fever. 

At the present time a few micro-organisms are recog- 
nized in the blood as diagnostic of existing diseased con- 
ditions. 

Spirillum of Kelapsing Fever. — To examine for 
spirilla a drop of blood is placed on a slide under a cover 
glass. They appear as fine, delicate spiral threads. 
Their length is about six times the diameter of a red 



SPIRILLUM OF RELAPSING FEVER. 



239 



blood corpuscle (Fig. 42). Attention is often called to 
their presence in blood by the disturbance their motion 
causes in the red blood corpuscles. They should be 
sought for with an oil-immersion lens and Abbe's con- 
denser. It is almost impossible to stain them, as they 
are destroyed by most staining solutions. 

The pneumococcus is sometimes found in the blood in 
cases of pneumonia or in malignant endocarditis due to 




Fig. 42.— Spirillum of Relapsing Fever. (Drawn by J. M. Byron, M.D., Loomis 
Laboratory. 

this organism. The method of Sittmann is the best 
procedure. Five or six cubic centimetres are drawn 
from an arm vein after careful sterilization of syringe 
and skin, and the blood is then expelled into sterile bouil- 
lon or into fluid agar, the temperature of which is 45° 
C.j and the agar and blood mixture is plated and grown 
in the thermostat at 37° C. The pneumococci appear in 
the blood about twenty-four to forty-eight hours before 
death. All cases in which the pneumococci have been 
found have not proved fatal; but it is in either fatal 



240 



PHYSICAL DIAGNOSIS. 



cases or in severe cases which often show metastatic 
infections from the germ. (For staining see Sputum.) 
In general septicaemia and in malignant endocarditis 



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Fig. 43.— Bacillus of Anthrax. (Drawn by J. M. Byron, M.D., Loomis Laboratory.) 

and in pulmonary tuberculosis with cavities streptococci 
and staphylococcus aureus and albus are often found in 




Fig. 44.— Bacillus of Typhoid Fever. X 700. (Drawn by J. M. Byron, M.D., Loomis 
Laboratory.) 

the circulating blood. To prove their presence Sitt- 
mann's method of procedure, as above described, should 
be employed. 



BACILLUS OF ANTHRAX. 241 

Bacillus of Anthrax. — This bacillus appears as a 
rod, straight or but slightly curved ; its length is from 
one to two diameters of a red blood corpuscle, and its 
breadth about one-sixth its length (Fig. 43). They may 
be joined so as to form chains. They can be seen with- 
out staining, or can be stained with a watery solution of 
methyl blue (two parts to the hundred). Mice and 
guinea-pigs are very susceptible to this disease. If blood 
from a case of anthrax (wool-sorter's disease) be injected 
into one of these animals, it shows immense numbers of 
bacilli in the blood in a short time. 

Bacillus of Typhoid Fever (Fig. 44). — This bacillus 
has been found in blood aspirated from the spleen. (See 
also Faeces.) Aspiration of the spleen is not justifiable, 
as it has caused death. 

Tubercle Bacillus. — In general miliary tuberculo- 
sis, tubercle bacilli are sometimes found in the blood. 
(For methods of staining, etc., see Sputum.) 

Plasmodium Malaria. — Amoeboid bodies have been 
found in the blood during a malarial paroxysm, by Lav- 
eran and other observers. Three varieties are now recog- 
nized: the tertian, quartan, and sestivo-autumnal. The 
youngest form of all of these types is an amoeboid body, 
which is a small, nonpigmented, hyaline spheroid. Just 
after a malarial paroxysm, or during the later part of it, 
these bodies are found free in the blood and in the red 
cells. 

In the tertian parasite these young forms appear in 
the red cells as highly refractive spheres showing slight 
but active changes in shape and position. They are 
from one-fifth to one-fourth the size of the red cell. 
Usually but a single parasite is present in a red cell, 

16 



242 



PHYSICAL DIAGNOSIS. 



though at times two or more may be seen in the same 
corpuscle. In twelve to eighteen hours after the chill 
the parasite occupies about one-third of the corpuscle, 
and the destroyed haemoglobin is seen as fine, nearly 
black pigment granules. In this stage the amoeboid 
movements of the parasite are very active, so that its 
form varies greatly. The pigment granules are also 







7 








Fig. 45. — A Parasite of Tertian Malaria (after Thayer). 1, Normal red cells; 
hyaline parasites ; 4, 5, 6, 7, pigmented forms ; 8, 9, 10, 11, segmentation. 



and 3, 



actively motile. The pseudopodia can be seen pervading 
the whole corpuscle ; by the union of two pseudopodia a 
ring shape is formed enclosing a bit of the corpuscular 
substance. This ring is coarser, larger, and more irreg- 
ular than the signet-ring form of the sestivo-autumnal 
parasite. The red cell is usually distinctly swollen. On 
the day of apyrexia the amoeboid movements are slug- 
gish but still present, while the pigment is actively 
motile. The full-grown parasite is larger or about the 
size of the swollen corpuscle around it. About the end of 



PLASMODIUM MALARIA. 243 

forty-eight hours the amoeboid movement practically 
ceases, and pigment collecu in a mass at the centre, and 
fine radiation appears from periphery to centre, dividing 
the parasite into from fourteen to twenty segments or 
spores. Each spore contains a fine central point sup- 
posed to be the nucleus. The cycle is completed by the dis- 
charge of the spores into the blood, and is coincident with 



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Fig. 46.— Parasite of Quartan Malaria (after Thayer). 1, Normal red cell; 2, hyaline 
parasite; 3 to 11, pigmented forms; 12 to 15, segmenting forms. 

the chill. The pigment freed is taken up by the leucocytes 
or deposited in the liver, spleen, and lymphatic organs. 

The segmentation of the tertian forms occurs mostly 
in the internal organs, and is not very common in the 
peripheral circulation. 

The quartan parasite completes its cycle of develop- 
ment in seventy-two hours and entirely within the circu- 
lating blood. The youngest forms are not distinguish- 
able from the young tertian. In a short time, however, 
they become more refractive and of sharper outline, and 



244 



PHYSICAL DIAGNOSIS. 



the amoeboid movements more sluggish and restricted. 
The pigment granules are coarser and darker than in 
the tertian. The red cell gradually loses its color, but 
does not swell as with the tertian, or become green or 
coppery-colored, as with the aestivo-autumnal. It is 
slightly decolorized and shrunken. The full-developed 
parasite is smaller than the red cell. After forty-eight 






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13 





14 



ts 




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Fig, 47.— Parasite of iEstivo- Autumnal Malaria (after Thayer). 1 to 6, young 
forms; 7 to 13, mature forms; 14 to 16, segmenting forms. 

hours the amoeboid movements cease and the pigment is 
quiescent. From six to ten hours before the return of the 
paroxysm the first phases of reproduction appear. The 
pigment gradually moves from the periphery toward the 
centre, often in definite radial stride. These regular striae 
of pigment are rarely if ever seen in the tertian form. 
The pigment finally concentrates in one or more coalesced 
masses of pigment at the centre. The segmenting striae 
appear and divide the parasite into from six to twelve 
pyriform segments, which rapidly become round or ovoid 



PLASMODIUM MALARIA. 245 

and separate from each other and the central mass. The 
red cell membrane ruptures, and the spores are free. The 
segmenting forms sometimes appear from six to eight 
hours before the chill, but most of them occur just before 
or during its onset. Of course all parasites do not ma- 
ture at the same instant, but each paroxysm corresponds 
with the maturation of one generation of parasites. 

The cycle of the cestivo-autumnal parasite is not 
definitely known. Welch gives it as from twenty-four 
hours or less to forty-eight hours or more. They develop 
mainly in the internal organs, spleen, and bone marrow, 
intestinal mucosa, and sometimes in the brain capillaries. 
The youngest forms closely resemble those of the ter- 
tian, but are readily distinguished when seen in the 
plasma or soon after entering the red cell. Ewing de 
scribes them thus: "In the plasma they move rapidly 
about with a peculiar rolling and darting motion, and 
exhibit three or four slightly projecting knobs, so that 
their shape is often that of a minute star with blunt 
points. In the cell they are slightly refractive, sphe- 
roidal, or ring-shaped bodies, showing rather active 
changes in form. In stained specimens, the earliest 
intracellular bodies are usually of the typical signet-ring 
form, but may be quite minute in size." It is not un- 
common to find two or more hyaline bodies in a single 
corpuscle. As they develop they show amoeboid move- 
ments and contain a few pigment granules. After from 
twelve to eighteen hours the characteristic signet-ring 
formation occupies about one-quarter to one-third of the 
red cell. The red cell may remain normal. It does not 
swell or become decolorized, but often is shrunken, 
creased, or otherwise deformed, and of a brassy color. 



246 PHYSICAL DIAGNOSIS. 

Sometimes a necrobiotic change occurs in which the 
haemoglobin separates from a part or whole of the outer 
part of the stroma and collects around the hyaline body. 
After twenty-four hours the parasites tend to disappear 
from the peripheral circulation, and the segmentation 
takes place in the internal organs. The pre-segmenta- 
tion forms become more refractive and homogeneous, and 
the pigment fuses into a single small block situated at 
the centre or near the periphery. The sporulation occu- 
pies a longer time than in the tertian or quartan, and 
takes place in groups; hence the long duration of the 
aBstivo-autumnal paroxysm. Sporulation is in general 
like the tertian but more irregular, and the spores are 
much smaller. The number of spores in each parasite 
varies from six to ten or less, to even thirty to fifty. The 
pigmented spheroidal body of this parasite, besides the 
regular sporulation, develops into the crescentic form. 
The young crescents appear in the general circulation on 
the third or fourth day, and the full-developed crescents 
by the fifth to seventh. The crescents measure from 9 
to 12 /* in length, and contain in the centre large, brown- 

1 





Fig. 48. —Flagellate Malarial Organisms (after Thayer). 

ish-yellow pigment granules. The remnant of the red 
cell membrane is often seen stretching across the concav- 
ity. These crescents are very resistant to quinine, and 
appear and last in the circulation for weeks whether or 



PLASMODIUM MALARIA. 



247 



not quinine has been given and the paroxysms have 
ceased. The crescents are supposed to be sterile forms 
of the parasites. 

Under certain unknown conditions flagellated forms 
develop from adult parasites. The flagellse are very mo- 
tile, and at times break off the parasite and move free. 
% % * 



Fig. 49. 



They are nearly transparent and difficult to see. They 
are bulbous on the ends and sometimes contain pigment 
granules. They develop in fresh specimens after the 
blood has been spread under the cover glass for a few 
minutes. Their biological significance is unknown. 




Fig. 50.— Filaria Sanguinis Hominis. (Instantaneous photograph by J. M. Byron,M.D.) 

In studying these organisms a fresh specimen is ob- 
tained by allowing a drop of blood on a cover glass to 



248 PHYSICAL DIAGNOSIS. 

spread out thin as the cover glass is dropped on to a slide. 
The amoeboid movements and motility of the pigment 
can be seen in such specimens. Stained specimens must 
be thinly spread and instantly dried, and then are best 
fixed in equal parts of alcohol and. ether for a half -hour 
or longer. A very light stain with eosin is necessary ; 
otherwise the early ring forms may be overlooked. The 
best stains are : 

Czenzyenski's fluid — 

Saturated aqueous solution methylene 

blue 20 c.c. 

One-half-per-cent solution of eosin in 

seveuty-five-per-cent alcohol 10 " 

Water . . . 20 " 

Stain from ten to fifteen minutes, wash in water, and 
mount in balsam. 

Plehn's solution — 

Concentrated watery solution methylene 

blue 60 c.c. 

One-half-per-cent solution eosin in sev- 

enty-five-per-cent alcohol 20 " 

Distilled water 40 " 

Twenty-per-cent KaOH 12 drops 

For this solution the specimens are hardened by im- 
mersion for three or four minutes in absolute alcohol and 
then stained for five or six minutes in the solution. 

Filaria Sanguinis Hominis (Fig. 50). — The filaria is 
found in the blood of people living in the tropics, or who 
have become infected there. The worm may give no 
symptoms beyond the urinary. 

Formerly it was believed that there was but one spe- 



FILARIA SANGUINIS HOMINIS. 249 

cies of Filaria, but it is now recognized that there are at 
least four if not five such hsematozoal embryos, each be- 
longing to a separate and distinct species, and each prob- 
ably having its own special pathological relations. The 
filarise sanguinis are described by Manson as long, slen- 
der, transparent, gracefully formed, snake-like organ- 
isms, which, when seen under the microscope in newly 
drawn blood, exhibit a remarkable activity in coiling and 
uncoiling themselves, in wriggling and lashing about in 
incessant and rapid movement among the corpuscles. 
They remain alive — their movements gradually slowing 
down, however — for days on the slide, provided the blood 
be kept from drying up and at an ordinary temperature. 
One species, Filaria diurna, appears during the day, dis- 
appearing during the night; another, Filaria nocturna, 
appears during the night, disappearing during the day ; 
whilst two species, Filaria Demarquaii and perstans, are 
constantly present both by day and by night. The first 
three species named are enclosed in long trailing sheaths, 
whereas Filaria perstans is unsheathed or naked. The 
best method of ascertaining the presence or absence of 
filarisG in the blood is to make a deep puncture in the 
finger, and, when a large drop has welled up, transfer the 
whole drop to the centre of a glass slide by dabbing 
the slide against the blood. Spread the blood with a 
needle evenly over the slide for an area of about an inch 
and a half and allow it to dry. Stain by immersing the 
slide for about an hour in very weak watery solution of 
fuchsin, one or two drops of a saturated alcoholic solution 
of fuchsin to an ounce of water; or more quickly in a 
two-per-cent solution of methylene blue. If it be found 
too deeply stained, it can be decolorized by washing for 






250 PHYSICAL DIAGNOSIS. 

a few seconds in a weak solution of acetic acid, three or 
four drops to an ounce of water. The specimen may be 
examined wet or dry and with or without a cover glass. 
Sixty or eighty diameters is a sufficient magnifying 
power. With the fuchsin solution the filariae and leuco- 
cytes are the only stained objects on the slide, To study 
the anatomy or movements fresh specimens must be 
used, Filaria diurna begins to appear in the peripheral 
circulation about 8 a.m., increasing in numbers till 12 or 
1 p.m., and decreasing from that time till about 9 p.m., 
when it disappears for the night, Filaria nocturna be- 
gins to appear in the peripheral circulation at about five, 
six, or seven in the evening, increasing up to midnight, 
then gradually disappearing, till by seven or eight in the 
morning all have disappeared save perhaps an occasional 
straggler, which may be found at any hour of the day. 
This filarial periodicity is constant and depends on the 
sleeping habits of the host, for if the host sleep during 
the day and keep awake during the night the periodicity 
is reversed. The filariae are probably taken into the 
human body in drinking water. In the case of the Fila- 
ria nocturna the female mosquito is the intermediary 
host. [For further details see Hanson's article in vol. 
iii., Allbutt's "System of Medicine."] 

Examination of the Sputum. 

CELLULAR ELEMENTS. 

To examine for cells, a small portion of sputum may 
be put on a slide and covered, without staining, or the 
specimen may be double stained for tubercle bacilli, 
when all the cellular elements except red blood corpuscles 
retain their form. 



SPUTUM. 251 

Epithelium. — Squamous cells from the mouth or vocal 
cords appear as large, flat cells, more or less granular. 
They may show fissures or folds. Columnar epithelium 
from trachea, bronchi, and nose is less often present; 
rarely are the cilia seen. 

From a clinical point the " alveolar " cells are the most 
important variety found in sputum. They are polygonal, 
with a granular protoplasm, and often show granules of 
pigment (carbon, blood pigment, iron, etc.) or fat glob- 
ules; their nuclei are made more distinct by the addition 
of acetic acid. The statement that they are the true 
alveolar cells is now questioned. Their presence indi- 
cates that the specimen of sputum is from deeper por- 
tions of the respiratory tract, whatever may be their 
origin, 

White Blood Cells or Pus Cells. — These are al- 
ways present in sputum. When an abscess ruptures 
into the lung, or in purulent bronchitis, they may consti- 
tute the entire cellular element. The}^ give the charac- 
teristic reaction to acetic acid. They often contain par- 
ticles of pigment. 

Liver cells may be found in sputum. They indicate 
the opening of an hepatic abscess into a bronchus. 

Bed Blood Corpuscles. — A few are always found. 
They show their characteristic appearance (see Blood), 
except when retained in the bronchi for some time, when 
hsBmatoidin crystals may be present. 

Curschmann's Spirals (Fig. 51). — These can often be 
seen by the naked eye. When magnified they are found 
to consist of a white central thread covered by fine fibres 
spirally arranged. They occur most often during 
asthmatic paroxysms and in capillary bronchitis. 



252 



PHYSICAL DIAGNOSIS. 



Bronchial Casts or Fibrinous Coagula (Fig. 52). 
— When the casts are of large size they are readily de- 
tected by the naked eye. Microscopic forms occur in 
pneumonia. In plastic bronchitis "they are long, and 



$L*J* 





Fig. 51. 



Fig. 52. 



Fig. 51.— Curschmann's Spirals, a, central thread . (After Curschniann.) 
Fig. 52.— Bronchial Cast. 

the terminal filaments may form a fine network in which 
epithelium and blood corpuscles are enclosed." 

Elastic Tissue. — Elastic fibres occur generally in bun- 




Fig. 53.— Elastic Tissue. (After vonJaksch.) 



dies, but they may retain the form of the alveoli (Fig. 
53). They vary considerably in length and thickness, 



SPUTUM. 253 

are curled, and have dark borders. To obtain these 
fibres free from mucus, etc., the sputum is put into a 
test tube, diluted with an equal bulk of water, and ten 
or fifteen drops of liquor potassso added. The mixture is 
then heated below the boiling point for a few minutes, 
and thoroughly shaken. By this process all the cellular 
elements are destroyed, but elastic tissue and micro- 
organisms are not affected. After standing for one or 
two hours, a small portion of the sediment is placed on a 
slide, covered, and examined. The presence of elastic 
fibres merely shows that destruction of lung tissue is 
taking place. They are found in tuberculosis, bronchi- 
ectasis, pulmonary abscess, and occasionally in pneu- 
monia. In pulmonary gangrene the fibres are generally 
destroyed in the lung by the ferments that are formed 
in that disease. 

PATHOGENIC BACTERIA. 

Tubercle Bacillus. — In collecting the sputum it is 
necessary to instruct the patient to expectorate into a 
clean cup or wide-mouthed bottle, being careful to save 
that portion which is raised after coughing. Frequently 
specimens are sent for examination that contain only 
the secretion from the pharynx and posterior nares. 
The diagnostic value of such sputum is of course 
nil, unless there is tubercular ulceration of these parts 
also. 

Staining Solutions. — A number of solutions have 
been proposed, and special advantages claimed for each. 
The following give satisfactory results and are the most 
stable : 



254 PHYSICAL DIAGNOSIS. 

No. 1. Ziehl-Neelson Fuchsin Solution — 

Fuchsin 1 1 part. 

Alcohol, ninety-five per cent 10 parts. 

Carbolic acid 5 " 

Water (distilled) 100 " 

Filter and keep in a well-stoppered bottle. 

No. 2. For Decolorizing — 

Nitric acid 1 part. 

Water 3 parts. 

Or a better solution is 0.3 per cent hydrochloric acid 
in ninety-five-per-cent alcohol. 

No. 3. For Double Staining — 

Methyl green or methyl blue 2 parts. 

Water 100 " 

Filter and keep in a dark bottle. 

Preparation and Staining of Specimen. — The por- 
tions of sputum most likely to contain the tubercle bacilli 
are the small, whitish, opaque masses. One of these is 
picked up with a clean platinum needle or steel pen in a 
holder, and transferred to a cover glass. Another cover 
glass is placed over it, and, after pressing out the excess 
of sputum, the two glasses are separated by quickly slid- 
ing one from the other. A thin film remains on each 
glass, and is allowed to dry spontaneously. When dry, 
the cover glass is passed slowly through the flame of a 
Bunsen burner or alcohol lamp three or four times to fix 
the film, so that it will not be washed off during the nec- 

1 Two kinds of fuchsin are in the market, the basic and acid. As 
tubercle bacilli only stain with the aniline dyes in alkaline solu- 
tions, the acid fuchsin is worthless. The bright crystalline fuchsin 
is for the most part basic. Acid alcohol also destroys the solution. 



PATHOGENIC BACTERIA. 255 

essary manipulations. Care must be taken that the 
cover glass is not heated too hot, as then the bacilli lose 
their affinity for the dye. Either of the following meth- 
ods may be employed for staining the specimen, but the 
second will be found more convenient : 

I. A small amount of solution No. 1 is put into a 
watch crystal, and the cover glass floated on it with the 
film down. The crystal is held over a flame until steam 
arises (do not allow the solution to boil). After a few 
minutes the cover glass is removed, and the excess of 
dye rinsed off in clean water. It is then submerged in 
solution No. 2 for a few seconds, and immediately rinsed 
in another vessel of water. If the film still retains a 
bright-red color, it must be dipped again in No. 2 and 
immediately rinsed. This can be repeated until it shows 
only a slight pink or rose tint. If this step is carried too 
far, then even tubercle bacilli will be decolorized and the 
distinctive test destroyed. 

The cover glass is now floated for about a minute, film 
down, on solution No. 3, in another watch crystal, and 
the excess of dye washed off in clean water. It is then 
ready to be placed on a slide and examined. 

II. The cover glass, ' film up, is seized in forceps ; 2 with 
a medicine dropper a few drops of solution No. 1 are 
poured upon it, and heated, b} r slowly passing through 

1 Instead of using" cover glasses to make the preparation, a 
number of specimens from different portions of the sputum can 
be placed on a slide, which is then treated as a cover glass, except 
that the cedar oil is placed directly on the film, no cover glass 
being used. 

2 Self -retaining forceps, made especially for this purpose, can be 
obtained from dealers m microscopes and supplies. 



25G PHYSICAL DIAGNOSIS. 

the flame of a lamp or burner several times, until steam 
arises. After a few minutes the dye is washed off, as in 
I., and solution No. 2 added. This is allowed to remain 
for a few seconds only. If the specimen is still too deeply 
stained, the process can be repeated until the desired rose 
tint is obtained. Lastly, a few drops of solution Xo. 3 
are allowed to remain on the glass for about a minute. 
This should be washed off in clean water. The prepara- 



V 



V 



Fig. 54.— Tubercle Bacilli from Sputum. X 900. (Drawn by J. 31. Byron, M.D., 
Loomis Laboratory.) 

tion can be dried and permanently mounted in Canada 
balsam. 

The tubercle bacilli can be detected with good No. 7 
objective, but it is better to use an oil-immersion lens 
and Abbe's condenser. 

The tubercle bacilli, stained red, appear as small, rod- 
like bodies, slightly curved. While individually they 
are about one-quarter the diameter of a red blood cor- 
puscle in length, two or three may be so grouped as to 
appear much longer. Portions of the protoplasm con- 



ACTINOMYCES. 257 

tained in them do not stain, but are seen as clear spots, 
giving the bacilli a beaded appearance (Fig. 54). It is 
unknown whether or not these clear spots are spores. 

The presence of bacilli in the sputum indicates tuber- 
culosis of the lungs or larynx. But absence of the 
bacilli does not indicate that there is no tuberculosis, 
unless repeated examinations have been made. In acute 
miliary tuberculosis they are rarely found. 

Actinomyces, or Ray Fungus. — These appear as 
bunches of pear-shaped bodies (Fig. 55). They are 
easily detected without staining. To facilitate the ex- 
amination, the suspected sputum may be treated with 
liquor potassae (see Elastic Fibres above), and the actino- 
myces looked for in the sediment; or they may be 
stained by Gram's method. Their presence in the 
sputum indicates the involvement of the lungs by this 
disease, whose symptoms and early physical signs are 
similar to those of tuberculosis. 

In examinations of sputum suspected of containing 
tubercle bacilli it is of the greatest importance to disin- 
fect the hands if they become soiled. Also to prevent 
the sputum from becoming dried and disseminated in 
the air. When a platinum loop is used to spread the 
sputum on a cover glass, great care must be observed 
not to allotv portions to snap off from the loop when 
brought near a flame. Carelessness in these details 
may have most serious consequences. 

Pneumococcus (Fig. 56). — The pneumococci of Fran- 
kel are found in the sputum in croupous pneumonia. 
Friedlander's method of staining them is to make cover- 
glass preparations of the sputum, as in the examination 
for tubercle bacilli. Treat the film for a minute with a 

17 



258 PHYSICAL DIAGNOSIS. 

one-per-cent solution of acetic acid, after which the 
specimen is allowed to dry in the air ; it is then placed 
for a few seconds in a saturated aniline- water-and- gen - 



Fig. 55.— Actinomyces, or Ray Fungus. X 850. (Drawn by J. M. Byron, M.D. 
Loomis Laboratory.) 



tian-violet solution; finally the dye is washed off with 
water and the cover glass mounted on a slide. Frankel 



Fig 56. — Pneumococcus. (After von Jaksch.) 

treats the cover-glass preparation with a weak, watery 
solution of methyl blue. The pneumococcus has been 



ECHINOCOCCUS. 259 

found in the saliva of healthy persons and in the sputum 

of cases of bronchitis. 

The bacillus of influenza is often present in large 

numbers in the sputum of patients suffering from a 

grippe bronchitis or pneumonia, and also in cases of 

tuberculosis in which an influenza infection has occurred 

some time previously. The bacilli are minute rods 

0.2-0.3 i>- broad by 0.5 ft long, occurring singly, rarely in 

chains of three or four members. They do not stain very 

easily with the aniline colors, and are decolorized by 

Gram's solution. At times they show a bipolar staining, 

when they may appear as cocci. A 

very dilute solution of ZiehFs solu- <&l j® b J§ * 

tion and water, in which the speci- \l • , /S ^\ 9 ^ .f2@ 

men is stained for fifteen minutes, % % <f^fe J^J' 

jj !L& i 6 Jy ®s 

gives very good results. In recent •* £ \^ <t& , & rjj 



cases the bacilli are found free in 

enormous numbers in the sputum, <x ~'°°° 

but after the bronchitis has lasted FlG - w.-ifchinococcus 

Hooklets. 

some time they are found only 

inside the cells. When found in the leucocytes they 
often stain poorly, as they are apt to be degenerated. 
They are often found in pure cultures inside the thick 
green pellets occurring in influenza sputum. 

Echinococcus. — Hooklets and portions of the cyst 
wall (Fig. 57) are found in the sputum when hydatid 
cysts in the lungs, pleura, or liver have ruptured into a 
bronchus. 

Amcebm coli may be found in the sputum if an 
hepatic abscess has opened up through the lungs. (See 
Fig. 84.) 



260 PHYSICAL DIAGNOSIS. 

The Examination of Diphtheritic Exudates. 

The early diagnosis of diphtheria is always of the 
greatest importance. Clinically it cannot always be 
differentiated from other inflammations of the fauces 
and tonsils. A direct examination may be made by 
rubbing off a portion of the exudate with a sterile plati- 
num loop or with a sterile cotton swab on a steel wire. 
The exudate thus obtained is then smeared with a drop 
of water on a cover glass, allowed to dry, and then fixed 
in a flame as with sputum slips, and stained for ten 
minutes with Loeffler's methylene-blue solution. For 
one accustomed to the appearance of diphtheria bacilli 
this is a fairly good method in some cases. But if no 
diphtheria bacilli are found, or if any doubt exists as to the 
nature of the bacilli present, a culture on Loefner's blood 
serum must be made. The exudate is obtained with a 
loop or swab as before, and then rubbed over the inclined 
surface of the blood serum. The serum tube is placed 
in a thermostat at 37° C. for from twelve to twenty-four 
hours. At the end of this time a platinum needle is 
swept over the various kind of colonies seen on the 
serum, and then smeared with a drop of water on a 
cover glass. This is allowed to dry, fixed in the 
flame, stained for ten minutes with Loefner's blue and 
mounted in balsam. The colonies of the diphtheria ba- 
cillus on blood serum at the end of ten or twelve hours 
appear as pearl gray or whitish-gray, slightly raised 
points, and are about equal in size with the colonies of 
streptococci; but by twenty-four hours the diphtheria 
colonies are larger than those of the streptococci and 
nearly equal in size those of the staphylococci. The 
diphtheria on the blood serum outstrip in their growth 
in the first twentv-four hours most of the other bacteria 



THE EXAMINATION OF DIPHTHERITIC EXUDATES. 261 

which may be present. In the cover-glass preparations 
made from the blood-serum tubes the diphtheria bacilli 
are found to possess the following characteristics, and are 
best described by Dr. W. H. Park: "The diameter of 
the bacilli varies from 0.3 to 0.8 v- and the length from 
1.5 to 6.5 //. They occur singly and in pairs, and very 
infrequently in chains of three or four. The rods are 
straight or slightly curved, and usually are not uni- 
formly cylindrical throughout their entire length, but are 
swollen at the end, or pointed at the ends and swollen 
in the middle portion. Even from the same culture dif- 
ferent bacilli differ greatly in their size and shape. The 
two bacilli of a pair may lie with their long diameter in 
the same axis, or at an obtuse or an acute angle. The 
bacilli possess no spores, but have in them highly refrac- 
tile bodies. They stain readily with the ordinary aniline 
dyes, and retain their color after staining by Gram's 
method. With an alkaline solution of methyl blue the 
bacilli, from blood serum especially, and from other 
media less constantly, stain in an irregular and extremely 
characteristic way. The bacilli do not stain uniformly. 
Certain oval bodies situated in the ends or in the central 
portion stain much more intensely than the rest of the 
bacillus. Sometimes these highly stained bodies are 
thicker than the rest of the bacillus; again, they are 
thinner and surrounded by a more slightly stained por- 
tion. The bacilli seem to stain in this peculiar way at a 
certain period in their growth, so that only a portion of 
the organisms taken from a culture at one time will 
show the characteristic staining. In old cultures it is 
often difficult to stain the bacilli, and the staining, when 
it does occur, is frequently not at all characteristic. It 
is important in making cultures from exudates that no 



262 PHYSICAL DIAGNOSIS. 

antiseptic, especially no mercurial solution, has lately 
been applied." Diphtheria bacilli persist in the throat 
for a longer or shorter time after all membrane has dis- 
appeared. Cultures should therefore be made from time 
to time until their disappearance is assured. 



- I 



ar# 



Fig. 27a.— Bacillus Diphtheriae. 

The formula for Lorner's methylene blue is as follows: 

Saturated alcoholic solution methylene blue. ... 30 c.c. 
Aqueous solution of KOH (1 : 10,000) 100 c.c. 

Loeffler's blood serum is composed of ordinary neutral 
bouillon of one litre of meat infusion, 1 per cent pep- 
tone, 0.5 per cent salt, and 1 per cent glucose. Three 
parts of serum are mixed with one of broth, and the mix- 
ture is run into small sterile tubes plugged with cot- 
ton. The tubes are inclined at an angle in a sterilizer 
and slowly brought up to a temperature just below the 
boiling point, and kept at this temperature, 90°-95°C., 
for two hours. Prepared in this manner they can be 
kept ready for use for months. 

Urine. 

The microscopical examination of the urine deals al- 
most exclusively with those elements that form the sedi- 
ment. The urine is allowed to settle in a conical glass; 
after a few hours a drop of the sediment is removed 
with a pipette and placed on a slide, under a cover glass, 



URINE. 263 

for examination. The constituents of the sediment may 
be divided into two groups: 1. Non-organized. 2. 
Organized. 

I. (a) AMORPHOUS DEPOSITS. 

Urates. — These usually appear as pale-pink, brown, 
or dark-red granular masses (Fig. 58), although at times 
the urate of soda has a globular form from which sharp 
spikes of uric acid project (Fig. 59). Urate of ammonia 
also at times assumes a spherical form, with or without 
small projecting spicula (Fig. 60). 

The urates are held in solution in normal urine at or 



&a ©HIS© & £u 





M 






Fig. 58. Fig. 59. Fig. 60. 

Fig. 58. — Urate of Soda. A, amorphous granules in clusters; B, granules in strings, 
sometimes mistaken for granular casts. X 250. 

Fig. 59. —Urate of Soda with Spicula. 

Fig. 60.— Urate of Ammonia. A , clusters of brown spherules ; B, isolated spherule 
with spicula—" the chestnut-burr " crystals. X 250. 



slightly below the body temperature. Their precipita- 
tion is favored by (a) acidity, (b) concentration, and (c) 
cooling of the urine. They appear in the urine in dis- 
orders of the digestive tract, and when the ingestion of 
nitrogenous food is beyond the needs of the body; in 
febrile conditions; and in diseases of the heart and lungs 
that prevent proper oxygenation. Too little exercise, 
close rooms, and excessive use of wine and malt liquors 
predispose to their appearance in the urine. Their per- 



264 PHYSICAL DIAGNOSIS. 

sistent presence without adequate cause is one of the 
diagnostic points of urinary calculi. 

Calcium Phosphate and Calcium Carbonate. — 
These are found in alkaline urine only. Calcium phos- 
phate occurs as minute granules and small spherical 
masses, or as angular particles. Calcium carbonate is 
almost always amorphous. Both are usually associated 
with the triple phosphates. 

Fat. — When fat occurs in the urine in small quan- 
tity, the condition is termed lipuria. The urine is tur- 
bid, but clears up on shaking with ether. The micro- 
scope discloses globules of varying size which strongly 
refract light. 

In chyluria, fat is present in large quantity and in a 
state of molecular subdivision. The urine has a milky 
appearance. Chylous urine most frequently depends on 
invasion of the urinary tract by the Filaria sanguinis 
hominis. 

(b) CRYSTALLINE DEPOSITS. 

Uric Acid. — Crystals of uric acid assume a great 
variety of forms, but as a rule they can be recognized 
by their color; the lozenge-shaped crystal is the com- 
monest form. If doubt exists as to the nature of an un- 
usual form, dissolve the crystals by adding a drop of 
caustic potash to the specimen, and then acidulate with 
a little hydrochloric acid ; if they are uric acid, they will 
recrystallize in one of the commoner forms (Fig. 61). 
All crystals of uric acid, as they appear in the urine, 
have the characteristic yellowish-red color. 

Uric acid appears in the urine under the same condi- 
tions that were mentioned for urates, with which it is 



URINE. 



265 



usually associated. Deficient action of the skin, from 
any cause, produces an excess of uric acid in the urine. 
It has a strong tendency to form around any small con- 
cretions in the urinary tract, giving rise to uric-acid 
calculi. 



4@2. 








Fig. 61. 



a 



b4 










Fig. 62. 



Fig. 61.— Uric Acid. A, the most common forms; B, disintegrated crystals; C 
formation of stellate masses. 
Fig. 62.— Calcium Oxalate. X 250. 



Calcium Oxalate. — This is generally deposited as 
small octahedra which strongly refract light, and more 
rarely in the hour-glass or dumbbell form (Fig. 62). 
" The prism of the triple phosphates sometimes appears 
octahedral, and the diamond-shaped crystals of uric acid 
are occasionally so small as to simulate the oxalates. 
Acetic acid dissolves the crystals of triple phosphates, 
and caustic potash causes the uric acid to disappear, 
while oxalate of lime resists both reagents." Crystals 
of oxalate of lime appear in the urine after eating ap- 
ples, pears, cauliflower, and the different varieties of 
sorrel, and after the administration of rhubarb; it is 



266 



PHYSICAL DIAGNOSIS. 



often present in diabetes mellitus, catarrhal icterus, 
gout, hypochondria, and after epileptic seizures. It is 
common in cases of mental exhaustion from overwork 
and excitement. The term oxaluria has been applied 
to that condition which, in addition to the abundant and 
persistent presence of calcium oxalate crystals, has a 
well-marked train of nervous and dyspeptic symptoms 
with a tendency to hypochondriasis. The mere finding 
of a few oxalate of lime crystals is not sufficient for this 
diagnosis. 

Ammonio-Magnesium or '-'Triple" Phosphates. — 
These crystals are found only in alkaline urine. During 





Fig. 63. Fig. 64. 

Figs. 63 and 64.— Ammonio-Magnesium, or " Triple " Phosphates. X 250, 



alkaline fermentation, urea is decomposed with the for- 
mation of ammonium carbonate ; this combines with the 
magnesium phosphate present to form the so-called 
triple phosphate crystals. When slowly formed the 
crystals assume the shape of triangular prisms with 
bevelled edges (Fig. 64 A), but when produced rapidly 
they have a feathery outline (Figs. 63 and 64 B). 



URINE. 



2G7 




Calcium Phosphate, although usually amorphous, 
may be deposited as angular crystals (Fig. 65). 

The precipitation of these salts in crystalline form 
does not necessarily indicate that they are excreted in 
excessive quantities, but shows that there 
has been some change in the reaction of 
the urine, due to alteration in some of 
its constituents which ordinarily retain 
these salts in solution. Excessive mental 
work or anxiety, and certain forms of 

n . -, ,, . -,., r ,-. . Fig. 65.— Calcium 

dyspepsia, reduce the acidity ot the urine Phosphate. 
and favor the precipitation of the earthy 
phosphates. Alkaline fermentation of the urine in the 
urinary tract causes their deposition on the mucous 
membrane and the subsequent formation of calculi. 

Cystin. — This body is occasionally found in the urine 
in crystalline form ; it occurs as six-sided plates (Fig. 
66). According to Baumann it is a normal constituent 
of urine, but the quantity eliminated in twenty-four 
hours is very small, amounting to 0.01 
gramme or less per litre. 

Little is known of the conditions that 
cause its elimination by the kidneys. It 
is often hereditary. Brieger has called 
attention to the relation of certain pto- 
maines in the intestinal tract and the 
appearance of cystin in the urine. It 
is also sometimes present in excess in the urine of tea 
tasters. It may lead to the formation of calculi. 

Leucin,. Tyrosin. — The urine may contain large quan- 
tities of these substances. Leucin appears in the form 
of spheres, resembling globules of fat (Fig. 67). When 




Fig. 66.— Cystin. 
X 250. 



208 



PHYSICAL DIAGNOSIS. 



these spheres are large they may show radiating lines 
and concentric rings. 

Tyrosin crystallizes in the form of fine needles ar- 
ranged as sheaves (Fig. 68). These bodies appear in 
those diseases in which oxidation is impaired, such as 
acute yellow atrophy of the liver, typhoid fever, small- 
pox, and in hepatic diseases generally. 





Fig. 



-Leucin. X 250. 



Fig. 68. -Tyrosin. X 250. 



Xanthix rarely occurs in the urine. It is of interest 
clinically only as it may form calculi. 



II. ORGANIZED. 



Mucus. — In healthy urine it is almost impossible to 
detect, microscopically, the small amount of mucus that 
is present, as its refractive power is the same as that of 
the urine. When it holds cells or crystals its presence 
may be inferred from the arrangement of these bodies. 
When excessive in amount it is often seen as trans- 
parent threads or cylindroids. Pus is changed by alka- 
line fermentation to a condition that resembles mucus. 
If small mucus threads are found in markedly alkaline 
urine with an ammoniacal odor, this fact must be con- 
sidered. 



URINE. 209 

Pus. — In acid urine pus cells have a distinct, circular 
outline, the protoplasm is granular, and the nuclei are 
more or less apparent. If acetic acid is allowed to flow 
under the cover glass, the corpuscles become slightly 
enlarged, they lose their granular appearance, and the 
nuclei become more prominent (Figs. 69 and 70). If 
the urine has undergone marked alkaline fermentation, 
the pus cells are destroyed (see Mucus, above). 

Pus J in the urine may come from any part of the 
urinary tract, or from the rupture of an abscess into it. 
When its origin is in the kidney, the normal reaction of 



*■"!■•>'.•-••!•■. 



v\..'.. 









-<- <*b 



Fig. 69.— Pus Corpuscles. Fig. 70.— Pus Corpuscles treated with 

Acetic Acid. 



the urine is retained, while in suppurative inflamma- 
tion of the bladder the reaction is alkaline when voided, 
or it soon becomes so. The epithelial elements associ- 
ated with the pus cells often decide what portion of the 
tract is involved. In women the accidental contamina- 
tion of the urine with pus from the vagina and uterus 
must be considered. Vaginal epithelium is then usually 

1 Frequently in examining urine a very few corpuscles, having 
all the appearances of pus cells, are found. These are claimed to be 
mucus corpuscles. Some observers affirm that while they react to 
acetic acid the same as pus cells, still if they exhibit only one or two 
nuclei they are mucus corpuscles. Their true character has an 
important financial bearing" to persons under examination for life 
insurance. 



270 



PHYSICAL DIAGNOSIS. 



present. The distinctive features of gonorrhoea! pus 
will be considered under Micro-organisms (page 274,). 

Blood. — Ked blood corpuscles are recognized by their 
size, color, and the peculiar change of light and shade 

in focussing. Frequently 
they become globular and 
pale, or their edges become 
crenated and the protoplasm 
granular (Fig. 26). They 
are rapidly destroyed by 
ammoniacal changes in the 
urine. Their presence indi- 
cates hemorrhage into the 
genito-urinary tract. The 
diseases of the kidney in 
which they most frequently 
occur are congestion, acute 
nephritis, calculus, cancer, 
and embolism. They may 
be found also in certain 
blood states, as purpura, 
scurvy, etc. In women the 
menstrual discharge may contaminate the urine. The 
other organic constituents (epithelium, casts, etc.) which 
may be associated with the blood corpuscles aid in deter- 
mining their origin. 

Epithelium (Fig. 71;. — Three principal varieties of 
epithelial cells are found in the urine : squamous cells, 
from the bladder, vagina, or orifice of the urethra ; co- 
lumnar cells, from the deeper layers of the pelvis of the 
kidney, or from the uterus — they may be, ciliated when 
from the uterus; and spherical cells, which have their 




Fig. 71.— B, superficial layers of blad- 
der; B 2 , deeper layers of bladder; V, 
cells from vagina; U, ciliated cells from 
cervix uteri; C, from uterine mucosa; 
P, from pelvis of kidney; T, from tu- 
bules of kidney ; G, from prostatic por- 
tion of urethra. 




URINE. 271 

origin in the tubules of the kidney, or from the deeper 
layers of the mucous membrane of the pelvis of the kid- 
ney, of the ureter, bladder, or ure- 
thra. Renal epithelium has a poly- 
gonal, well-defined outline, is slightly 
larger than a pus cell, and has a 
large oval nucleus. The presence of 
such cells in a cast at once deter- 
mines their origin. Tailed cells from 
the superficial layer of the pelvis of 
the kidney are sometimes found. 

Spermatozoa. — When found in urine, these bodies 
have the characteristic tadpole appearance (Fig. 72), but 
they no longer possess any power of motion. 1 They are 
present immediately after all seminal emissions; often 
after defecation, especially if constipation is extreme; 
and after epileptic seizures. They have been found in 
the urine of women after coitus. They are occasionally 
found in typhus and typhoid fevers. 

Casts. — These are moulds of the tubules of the kid- 
ney, formed by the effusion of materials that coagulate 
spontaneously. They often enclose formed elements. 
Their diameter varies from z ^ to ytutf mcn j or even 
smaller. 

Hyaline. — Hyaline casts are transparent, structure- 
less cylinders, often invisible with strong illumination. 
Their extremities are generally rounded or slightly 

J In medico-legal cases (rape) the vaginal discharge should be 
examined for spermatozoa. Pieces of clothing' supposed to be 
stained with seminal fluid are macerated with distilled water in a 
test tube, for a short time ; after shaking thoroughly, the pieces are 
removed, the sediment allowed to settle and examined. 



272 PHYSICAL DIAGNOSIS. 

clubbed, but, from a tendency to fracture transversely, 
fragments are often found with straight ends (Fig. 73). 
Small hyaline casts are found in the acute (inflamma- 
tory) stage of nephritis, when they are generally associ- 
ated with other varieties, and the urine is markedly 
albuminous. Large hyaline casts are found in the atro- 
phic stages of all forms of Bright's disease. Hyaline 
casts may have pus cells or renal epithelium adhering 
to their surface. At times a few hyaline casts are 

n 





Fig. 73.— Types of Hyaline Casts. 

found in urine that is non-albuminous and contains no 
other evidence of kidney disease. This is most apt to 
occur in the atrophic form of chronic nephritis. 

Waxy casts are a variety of hyaline. Generally they 
are of yellowish color. At times they give the amyloid 
reaction with iodine and iodide of potash, but this is not 
pathognomonic. 

Epithelial. — These show the characteristic epithelium 
of the tubules of the kidney. The cells may have a 
normal appearance, or are more or less broken down and 
degenerated. The casts may be composed entirely of 
renal epithelium, or a few cells only may be entrapped 
in a hyaline cast (Fig. 74). 

Epithelial casts are present in desquamative nephritis. 
When pus cells are mingled with renal epithelium in 



URINE. 



273 



casts, the inflammatory changes in kidney are exten- 
sive. 

Granular. — Granular casts vary greatly in size, color, 
and appearance. Their outline is well marked, and one 





Fig. 74.— Epithelial Casts. 



Fig. 75.— Granular Casts. 



or both ends generally rounded (Fig. 75). The granular 
matter may be composed of the debris of epithelium, 
pus, or blood. In the early stages of nephritis they are 
associated with epithelial casts. When granular casts 






Fig. 76.— Fatty Casts. 



Fig. 77.— Blood Casts. 



only are present, they indicate the large, white kidney, 
or that extensive destruction of the parenchyma of the 
kidney is taking place. 

Fatty. — The oil globules may be in degenerated epi- 
thelium (a variety of granular casts), or may themselves 
constitute the cast (Fig. 76). This variety is indicative 

18 



274 



PHYSICAL DIAGNOSIS. 



of the large white kidney, or the contracted kidney with 
marked fatty degeneration. 

Blood (Fig. 77). — The presence of a few red blood cor- 
puscles in an epithelial cast indicates the acute stage of 
kidney disease. When they constitute the entire cellu- 
lar element they are diagnostic of renal hematuria. 
When they appear without other evidences of acute con- 
gestion of the kidney, or traumatism, disease of the 
renal blood-vessels, especially amyloid or fatty degenera- 
tion of the Malpighian tuft, must be considered. 

Casts composed of micrococci are often present in 
septic embolism of the kidney. 1 



MICRO-ORGANISMS. 



Non-pathogenic. — These include those forms found 
in urine that has undergone fermentation. When pres- 




Fig 78.— Torula Cerevisise, Fig, 




. — Penicilium Glaucum. 
X 200. 



Or 



Fig. 80.— Sarcinse. 
X 800. 



ent in freshly voided urine they indicate that this proc- 
ess is going on in the urinary tract. 

The most common forms are : Torula cerevisiae (Fig. 
78), found in diabetic urine ; Penicilium glaucum (Fig. 

2 The microscopical appearance of extraneous matter, as hair, 
fibres of silk, linen, cotton, etc., should be so well known as not 
to be mistaken for casts. 



URINE. 



275 



79) ; a small form of Sarcina (Fig. 80) ; and Micrococcus 
ureae. 

Pathogenic Gonococci. — These are spheroidal bodies, 
occurring in pairs (diplococci) or groups of pairs. Be- 
tween the associated cocci there is a slight space. Their 
opposing sides are somewhat flattened, giving the char- 
acteristic coffee-bean appearance. They must be stained 
to be demonstrated. 

A drop of pus from the urine, or direct from the 
meatus urinarius, is smeared upon a cover glass, which, 




Fig. 81.— Gonococci. 



after it has dried, is passed slowly through a flame to 
fix the film. A few drops of a solution of methyl blue 
(see Sputum) are placed on the specimen for a few min- 
utes, the excess of dye is washed off, and the specimen 
examined with an oil-immersion lens or a No. 7 objec- 
tive. Gonococci, stained blue, appear free on the epi- 
thelium and in the pus cells (Fig. 81). The diagnostic 
feature is the presence of the gonococci in the pus cells, 
and that the gonococci are decolorized by Gram's stain. 
In the urethra non-pathogenic diplococci are sometimes 



276 PHYSICAL DIAGNOSIS. 

found. They are slightly larger than gonocococi, and 
may exist free or in the epithelial cells, but are not 
found in the pus cells. 

Gonococci in pus, whether urethral, vaginal, or con- 
junctival, are diagnostic of gonorrhceal infection. 

Tubercle Bacilli are indicative of tubercular ulcera- 
tion somewhere along the genito-urinary tract. (For 
method of staining, etc., see Sputum.) 

Actinomyces may appear in the urine when the genito- 
urinary tract is primarily or secondarily involved. 

PARASITES. 

Filaria Sanguinis Hominis (Fig. 50, page 247). — 
These bodies often appear in the chylous urine of pa- 
tients whose blood is infected. In addition to the oil 
globules, pus and blood may be found in the urine. 

Echinococci, hooklets, and portions of cysts may ap- 
pear in the urine when a hydatid cyst has formed in the 
genito-urinary tract or ruptured into it from neighbor- 
ing organs (Fig. 57, page 259). 

Vomit. 

The vomit may contain elements from the oesophagus 
and respiratory tract besides the contents of the stom- 
ach. The microscopical examination may show tho 
presence of food masses, such as muscle fibres, with 
well-marked striations, oil globules, needle-shaped fat 
crystals, connective-tissue fibres, starch granules more 
or less altered, and vegetable cells. These, of them- 
selves, are of no diagnostic value, but may give a hint 
as to the rapidity of the digestive process. 

Ked Blood Corpuscles, showing their characteristic 






VOMIT. 277 

appearance, may be found in the vomit where hemor- 
rhage into the stomach has been so great and its expul- 
sion so rapid as not to allow the gastric juice to act 
upon them, or when blood is added to the vomited mat- 
ter above the stomach. When acted on by gastric juice 
the corpuscles are destroyed, and their contents appear 
as masses of reddish-brown pigment (coffee-grounds). 
To determine the presence of blood in such cases, some 
of the suspected matter is dried, ground into a powder, 
and placed on a slide. A few crystals of common salt 
are added, and a cover glass put on. A little glacial 
acetic acid is allowed to flow 
under the cover glass, and the ^\ 



slide is heated (not to boiling) ^* ^^ 

for a few minutes. The salt is r% ^0> w* f 
dissolved out in a little water. /) (/&& \^ 

If the specimen contains blood, * ^+ \ 

small, dark, rhombic crystals of | X <&• 

hsemin will be seen (Fig. 82). fr Mmm ^^ 

Pus Cells are also destroyed W 

by gastric juice. They only ap- Fi& 82 _ Haemin Crystals< 

pear in the vomit when there 

is a suppurative inflammation of the stomach walls, 
or when a large abscess has ruptured into the stomach. 

The Epithelial Cells found in the vomit are of the 
squamous or columnar type. Squamous cells come from 
the oesophagus or mouth ; columnar cells from the gas- 
tric mucous membrane. 

Sarcin^e ventriculi, having the characteristic " wool 
pack " appearance (Fig. 80, page 274), are often found. 
They are present when the stomach retains its contents 
for a long time, especially in dilatation of the organ. 



273 PHYSICAL DIAGNOSIS. 

Tubercle Bacilli, when found in the vomit, indicate 
a tubercular ulceration in the food passages or contam- 
ination of the vomit by sputum. 

The chemical analysis of the gastric contents is often 
of great assistance in diagnosis. For accurate deter- 
minations of the digestive powers of the stomach we 
must have known contents for digestion secured at defi- 
nite periods during the digestive process. Test meals 
therefore are employed. 

The test breakfast of Ewald consists of thirty-five to 
seventy grammes of wheat bread and three hundred to 
four hundred cubic centimetres of water or weak tea 
without sugar. As traces of lactic acid are formed dur- 
ing the early stages of the digestion of this meal, Boas' 
test meal should be used when especial importance is 
attached to the presence of this acid. This meal con- 
sists of one tablespoonful of rolled oats and one quart of 
water boiled down to one pint. The contents of the 
stomach are obtained one hour later. The double test 
meal of Salzer consists of thirty grammes of lean cold 
beef hashed fine so as not to obstruct the stomach tube, 
two hundred and fifty cubic centimetres of milk, sixty 
grammes of rice, and one soft-boiled egg. Exactly four 
hours after the ingestion of this meal Ewald 's test meal 
is taken, and one hour later the stomach contents with- 
drawn. The gastric juice is thus obtained at the height 
of digestion, and some idea of the motor power of the 
stomach may also be formed. Under normal conditions 
no remains of the first meal should be found in the 
stomach at the time of examination. Test meals must 
be given in the morning on an empty stomach. If there 
be retention of food the stomach must be washed out on 



VOMIT. 279 

the previous evening. The stomach contents are ex- 
pressed by means of a stomach tube, and the amount 
obtained after Ewald's meal is usually from fifteen to 
sixty cubic centimetres. 

The tube is like a large soft rubber catheter with a 
hole in the end and two on the sides near the tip. It 
should be about thirty-six inches long and should be 
introduced for twenty-four to twenty-six inches of its 
length. The tube is introduced to the posterior wall of 
the pharynx ; the patient then bending the head slightly 
forward, the tube is pushed down till resistance is felt 
when it touches the floor of the stomach. The pa- 
tient may be told to swallow during the process. If the 
gastric contents do not flow out readily the patient 
should bear down with the abdominal muscles or cough 
a little. If this is insufficient aspiration may be used. 
Simon recommends suction with the mouth, with the 
fingers slightly compressing the tube near the patient's 
mouth to feel the contents as they flow by the fingers. 

The normal gastric juice is acid from free hydrochloric 
acid and acid combined with proteids and salts. The 
secretion of hydrochloric acid begins immediately after 
the ingestion of food ; the time of appearance of free HC1 
in the gastric contents depends on the amount and kind 
of food taken. After an Ewald meal it appears free 
in from fifteen to thirty minutes. It gradually in- 
creases in amount, and after a light meal reaches in one 
and one-half to two hours from .05 to .19 per cent, and 
after a full meal in two to three hours from .2 to .33 
per cent. Lactic acid, when present, is the result of 
abnormal fermentation of the food or has been in- 
gested. 



280 PHYSICAL DIAGNOSIS. 

Tests for free HCL — With Gunzberg's reagent, 
which consists of : 

Phloroglucin 2. gm. 

Vanilin 1. " 

Absolute alcohol 30. cc. 

This solution must be kept from the light, in a dark- 
colored bottle. A few drops of the gastric juice or un- 
filtered gastric contents are placed in a clean porcelain 
dish and an equal number of drops of the reagent added ; 
the mixture is then slowly evaporated by gentle heat — 
boiling or rapid evaporation are to be avoided. In the 
presence of free HC1 a rose tint or fine rose-colored lines 
develop, the depth of color varying with the amount of 
acid present. A brown, brownish-yellow or brownish- 
red color indicates that excessive heat has been applied 
or that free HC1 is absent. 

Topfer^s Test. — The reagent is a 0.5-per-cent alcoholic 
solution of dimethyl-amido-azo-benzol. One or two 
drops of this solution are added to a trace of gastric 
contents, which need not be filtered. If free HC1 be pres- 
ent a beautiful cherry red develops, varying in intensity 
with the amount of HC1 present. Loosely combined 
HC1 and acid salts do not produce this color. In the 
absence of free HC1 a yellow color results, the fluid be- 
coming cloudy and fluorescent. This test is more than 
twice as delicate as that with the Gunzberg reagent. 

It is important to obtain the total acidity of the stom- 
ach contents in order to calculate the total production of 
HC1, free and combined, and the amount of organic 
acids and acid salts present. To obtain these results a 
decinormal sodium hydrate solution must be titrated 
against the filtered gastric juice, using as indicators cer- 



VOMIT. 281 

tain coloring agents which react to the various acid 
principles as found in the gastric contents. 

The decinormal sodium hydrate solution is made and 
standardized, the method given by Simon being the easiest 
of application. " One-tenth gramme of pure crystallized 
oxalic acid is dissolved in distilled water, and the solution 
titrated with the decinormal sodium hydrate solution 
purposely made too strong by adding four grammes 
NaOH to a little less than one thousand cubic centime- 
tres distilled water, which is to be corrected, using two 
or three drops of a one-per-cent alcoholic solution of 
phenolphthalein as an indicator, until the rose color does 
not disappear on stirring; 15.9 cubic centimetres should 
bring about this result. As the NaOH solution, how- 
ever, has been purposely made too strong, less will be re- 
quired. The amount of water that must be added in 
order to bring the solution to its proper strength is de- 
termined by the formula C = ~, in which C represents 
the number of cubic centimetres of water which must 
be added to the remaining solution, N the total number 
of cubic centimetres remaining after one titration, n the 
number of cubic centimetres consumed in one titration, 
and d the difference between the number of cubic centi- 
metres theoretically required (15.9 c.c.) and that actu- 
ally used in one titration. The solution having thus 
been properly diluted, the correctness of its strength is 
again tested and a further correction made if necessary, 
until absolute accuracy has been obtained." 

The indicators used are as follows: (I) 0.5 per cent 
alcoholic solution of dimethyl-amido-azo-benzol (amido- 
benzol) which reacts only to free acids such as free HOI. 

(2) A one-per-cent aqueous solution of alizarin mono- 



282 PHYSICAL DIAGNOSIS. 

sulphonate of sodium (alizarin) which reacts to organic 
acids, acid salts, free HC1, but not to loosely combined 
HC1. 

(3) Phenolphthalein which reacts to organic acids, 
acid salts, free HC1, and combined HC1. 

One cubic centimetre of decinormal soda solution neu- 
tralizes .00365 gramme HC1. 

Into each of three small porcelain dishes are measured 
five cubic centimetres of filtered gastric contents and 
diluted with equal amounts of distilled water. Into No. 
1 one to two drops of amido-benzol are added, which if 
free HC1 be present, turns bright red. From a gradu- 
ated burette the decinormal soda solution is added, drop 
by drop, until on stirring the last traces of red have dis- 
appeared and the fluid is of bright lemon-yellow color, 
indicating the end of the reaction. The quantity of 
soda solution used is noted and the free HC1 computed. 
Into No. 2 one to two drops of alizarin are added and 
the solution titrated. A deep violet color indicates the 
end reaction. From the quantity of soda solution used 
may be computed the acidity due to all acid principles 
excepting loosely combined HC1. 

Into No. 3 add one to two drops of phenolphthalein 
and titrate as before. The end reaction is reached when 
the red color obtained no longer darkens on further ad- 
dition of the alkali. From the quantity of soda solution 
used compute the total acidity of the specimen. 

To determine the combined HC1 subtract the result of 
No. 2 from that of No. 3. 

To determine the total HC1, free and combined, add 
the result of No. 1 to the difference between Nos. 2 and 3. 
Where free HC1 is present all the combined acid is HC1. 



vomit. 283 

To determine the acidity due to organic acids and acid 
salts subtract the result of No. 1 from that of No. 2. 
The sources of error with this method are: (a) the diffi- 
culty of determining accurately the end reaction, espe- 
cially with alizarin. To obviate this Topfer recommends 
the following controls: (1) To five cubic centimetres of 
distilled water add one to two drops of alizarin ; a 
clear yellow color is obtained. (2) To five cubic centi- 
metres of a one-per-cent solution of disodium phosphate 
add one to two drops of alizarin, when a red or slightly 
violet color will result. (3) To five cubic centimetres of 
a one-per-cent solution of sodium carbonate add the one 
or two drops of alizarin, and the clear violet color to be 
obtained as the end reaction will appear. 

(b) Amido-benzol reacts to the organic acids, lactic, 
acetic, and butyric, as well as to free HC1. But these 
acids are not usually present when the stomach contains 
free HC1, and besides the dissolved albumins practically 
nullify their disturbing effects. 

The presence of lactic acid in the gastric contents may 
be shown by Kelliug's test: Dilute five to ten cubic 
centimetres of filtered gastric juice with ten to twenty 
parts of water, and add one or two drops of a five-per- 
cent aqueous solution of sesquichloride of iron. If lactic 
acid be present a distinct green color is seen when the 
test tube is held to the light. This reaction occurs only 
in the presence of lactic acid ; the test is, therefore, more 
reliable than that of Uffelmann. 

For a quantitative estimation of lactic acid Boas' 
rapid test is sufficiently accurate for clinical purposes: 
A few drops of dilute H,S0 4 are added to ten cubic cen- 
timetres of filtered gastric juice, and the albumin present 



284 PHYSICAL DIAGNOSIS. 

is removed by heat. The filtrate is evaporated to a syrup 
on a water bath. Ten cubic ceutimetres of water are 
added, and the solution is again evaporated to a small vol- 
ume ; this eliminates the fatty acids. The fluid is shaken 
with two hundred cubic centimetres of ether, allowed to 
settle, and the ether decanted. The ether is then evapo- 
rated by placing the evaporating dish in hot water {keep 
all flames aivay). The residue is taken up with water 
and titrated with decinormal sodium hydrate solution, 
using phenolphthalein as an indicator. The number of 
cubic centimetres of decinormal soda solution used mul- 
tiplied by 0.009 gives the amount of lactic acid in the 
ten cubic centimetres of gastric juice. 

Butyric acid may be recognized by Boas' test: Ten 
cubic centimetres of gastric juice are extracted with 
fifty cubic centimetres of ether; the ether is then evapo- 
rated and the residue taken up with a little water, and a 
few crystals of calcium chloride are added. Butyric 
acid, if present, will separate out in oily drops, and can 
be recognized by its rancid odor. 

Boas also recommends the following test for acetic 
acid : Ten cubic centimetres of filtered gastric juice are 
extracted with ether. After the evaporation of the 
ether the residue is taken up with a few drops of the 
water, and the solution carefully neutralized with dilute 
NaOH. A few drops of dilute ferric-chloride solution 
are added, when a deep blood-red color will be obtained 
if acetic acid be present. 

Quantitative Estimation of the Fatty Acids. — 
McNaught's modification of Cahn-Mehring's method. 
Ascertain the total acidity of ten cubic centimetres of 
gastric juice. Evaporate another ten cubic centimetres 



VOMIT. 285 

to a syrup, take up with water, and obtain the total 
acidity. Tho difference between the results equals the 
acidity due to the fatty acids. 

To prove the presence of chymosin or rennet ferment 
Leo's method is to be preferred : To five or ten cubic 
centimetres of raw milk in a test tube three to five drops 
of gastric juice are added and placed in the thermostat 
at 37° C. If in ten to fifteen minutes coagulation takes 
place the chymosin is present. 

To test for the chymosinogen ten cubic centimetres of 
filtered and faintly alkaline gastric juice are mixed with 
two to three cubic centimetres of a one-per-cent calcium 
chloride solution, or the gastric juice is rendered faintly 
alkaline with lime water and mixed with five to ten cubic 
centimetres of milk; the mixture is then kept at 37° 
C. If the chymosinogen is present a thick casein coag- 
ulum is formed in a few minutes. 

When it is desirable to prove definitely the absence of 
pepsin and pepsingen in the stomach the method of 
Jaworski is to be preferred. Two hundred cubic centi- 
metres of decinormal hydrochloric acid are poured into 
the stomach through a stomach tube and siphoned out 
after half an hour. Ten to twenty cubic centimetres of 
this fluid are placed in test tubes, and small pieces of 
coagulated egg albumen being dropped into the tubes, 
they are placed in a thermostat at 37°— ±0° C. If no 
solution of the albumin takes place there is no pepsin 
nor pepsinogen in the fluid. 

The clinical estimation of the products of the diges- 
tion of the carbohydrates may be disregarded. 

The digestion of the albumins in the stomach is de- 
pendent on the HC1 and pepsin present. They are 



286 PHYSICAL DIAGNOSIS. 

broken down into their various proteoses and either pass 
as such into the intestines or are farther changed into 
peptones. Casein, however, is first coagulated by the 
chymosin, and then broken up into the caseoses and 
nuclein by the HC1 and pepsin. The time required for 
this digestion is of clinical importance, and may be esti- 
mated by examining the gastric contents at stated inter- 
vals. But the estimation of the various proteoses is not 
clinically important. As stated above, five hours after 
the ingestion of the Salzer test meal all remnants of the 
albuminous ingredients should have disappeared. This 
may also be used as an estimate of the motility of the 
stomach. The absorptive power of the stomach may be 
roughly indicated by Penzoldt's test: When ^ve graius 
of potassium iodide are taken in a gelatin capsule iodine 
appears in the urine and saliva of the normal subject 
within six to fifteen minutes, while with deficient ab- 
sorptive powers its appearance is much later. The iod- 
ine may be detected by applying a few drops of urine or 
saliva, and one drop of strong nitric acid, to starch paper, 
which in the presence of iodine turns blue or violet. 

The Clinical Significance of the Examination of the 
Gastric Contents. 

SIGNIFICANCE OF HYDROCHLORIC ACID. 

A normal percentage of .2 to .3 per cent of HC1 in 
the gastric contents argues strongly against organic dis- 
ease of the stomach. When, however, all symptoms 
point to disease of the stomach, a normal percentage of 
HC1 points to a nervous dyspepsia or atony of the mus- 
cular wall. 



VOMIT. 287 

With a constant subacidity (HC1 below . 1 per cent; 
one must think of a subacute or chronic gastritis. It 
also occurs with ulcer of the stomach or duodenum, with 
incipient carcinoma and atony of the stomach. 

A constant hyperacidity (HC1 over .2 per cent) occurs 
most frequently in nervous dyspepsia. It may be pres- 
ent in the early stages of chronic gastritis. It is not 
uncommon with simple ulcer; it points strongly against 
carcinoma, but may indicate a neoplasm developing in 
the cicatrix of a former ulcer. 

Anacidity is the most frequent symptom of the later 
stages of chronic gastritis; it is not an uncommon symp- 
tom in nervous dyspepsia, especially in the form follow- 
ing eye strain from astigmatism. In gastritis pepsin 
also is usually absent, while it is present in nervous 
dyspepsia. It is strong evidence of carcinoma when 
confirmatory symptoms are likewise present. 

A variable acidity indicates in all probability a ner- 
vous dyspepsia. 

Lactic acid is not formed in appreciable amounts 
during normal digestion even after the ingestion of car- 
bohydrates. When found under these conditions it has 
been taken as such with the food. Boas found only 
traces in chronic gastritis, atony and dilatation of the 
stomach, and in nervous dyspepsia. It may be present 
in larger amounts in dilatation of the stomach with 
stagnation of its contents. The production of lactic 
acid points strongly to carcinoma, and if accompanied 
with stagnation in the stomach and a diminution of 
HC1, the presence of carcinoma, even in the absence of a 
tumor, is extremely probable. On the other hand, the 
absence of lactic acid does not exclude carcinoma. 



288 PHYSICAL DIAGNOSIS. 

The occurrence and significance of butyric and acetic 
acids are, in general, the same as of lactic acid. Before 
drawing any deductions from their presence, however, 
the previous ingestion of butter and fats as a source 
of butyric acid and alcohol of acetic acid must be ex- 
cluded. 

Fceces. 

The number and character of food residues found in 
the faeces depend upon the diet. In a general mixed 
diet there will be found vegetable cells, starch granules, 
muscle fibres, elastic and white fibrous tissue, and fat 
globules ; while in the stools of children and adults fed 
exclusively upon milk large quantities of fat and crys- 
tals of fatty acids will be found. 

Red Blood Corpuscles do not present their charac- 
teristic form unless a large quantity of blood has been 
thrown into the intestines and rapidly voided, or its ori- 
gin is in the lower portion of the large intestine, as 
from haemorrhoids (in women contamination with the 
menstrual flow must be considered). When blood has 
been retained for some time, no corpuscles can be de- 
tected, but it is changed to a " tarry " or dark-brown 
mass (see Vomit). 

Pus Cells are rarely present in healthy stools. In 
simple intestinal catarrh only a few are present. When 
found in large numbers they are due to ulceration of 
some portion of the intestinal tract. Pure purulent dis- 
charges take place only when an abscess has ruptured 
into the intestines, and occasionally in dysentery. 

Epithelium, in small amount and more or less al- 
tered, is always found in healthy faeces and has no diag- 



F.ECES. 289 

nostic significance. When found in large quantity it is 
indicative of intestinal catarrh. 

MICRO-ORGANISMS. 

Large numbers of micro-organisms are found in the 
f seces ; most of them are non-pathogenic. Some which 
are found in unhealthy stools are also present in the 
healthy — they seem to be concomitants, and not ex- 
citants, of the diseased condition. 

The pathogenic bacteria are the — 






Fi«. 83.— Spirillum Cholerae Asiaticee. From a culture. 

Cholera Bacillus {Comma Bacillus). — This appears 
as a short, curved rod that is thicker than the tubercle 
bacillus (Fig. 83). Two bacilli may be so placed as to 
give the peculiar S-like appearance. They are found 
most abundantly in the free mucous flocculi of the rice- 
water discharges. A cover-glass preparation may be 
made and stained with methyl blue, as for gonococci. 

Bacillus of Typhoid Fever {Bacillus of Ebertli). — 
This appears as a rod with rounded extremities; its 
length is about one-third the diameter of red blood cor- 
puscles, and its width one-third its length (Fig. 44, 
page 240). Vacuoles are sometimes seen in the rods. 
They stain with a watery solution of methyl blue. 

The bacilli of cholera and typhoid fever as they appear 
in the faeces cannot be differentiated by their appear- 
ance, or by their reaction with the staining solutions, 

19 



290 



PHYSICAL DIAGNOSIS. 



from other bacteria having similar form. To decide 
their true nature it is necessary to make cultures. The 
best medium for the differentiation of typhoid bacilli is 
that of His and Capaldi. This requires such special bac- 
teriological knowledge and technique that the student 
is referred to special works on bacteriology. 

Tubercle Bacilli may be found in the stool when 
there is tubercular ulceration of the intestine, or when 
tubercular sputum has been swallowed. 



ANIMAL PARASITES. 



Amceb^e Coll — These are cellular bodies, three to 
four times as large as a pus cell, from 25 to 35^ in diam- 
eter, having a vesicular nucleus and often fine nucleo- 




Fig. 84.— Amoebae Coli. From the intestinal wall 
specimen prepared by Prof. W. J. Councilman. 



near an ulcer. Drawn from a 



lus, both apt to be centrally placed. Their protoplasm is 
finely granular and may contain vacuoles, coarser gran- 
ules, bacteria, and red blood cells. When seen imme- 
diately after voiding, they often show amoeboid move- 
ments (Fig. 84). They have important diagnostic 
significance in relation to dysentery and abscess of the 
liver. 



FAECES. 291 

Only certain intestinal worms and their ova will be 
considered. Von Jaksch describes them as follows: 

Distoma Hepaticum. — This is a leaf -shaped worm 
measuring twenty-eight millimetres by twelve millime- 
tres. The head is short, and furnished with a sucker. 
There is another sucker on the ventral aspect, and be- 
twen the two the genital pore is situated. The latter 
leads to a uterus which is convoluted like a ball of wool. 




Fig. 85.— Distoma Hepaticum . About natural size. 

The eggs are oval, 0.13 millimetre long by 0.08 milli- 
metre broad. One extremity is broader than the other 
and opens with a lid ; the shell is brown and is composed 
of two layers. 

T^nia Solium. — The taenia solium is not a common 
parasite in America. It may measure upwards of three 
to six feet. Its head is quadrilateral, about as large as 
a pin's head (-j^ - ^ of an inch), and dark in color. This 
is succeeded by a delicate, thread-like neck about an inch 
in length and unjointed. The segments or proglottides, 
which form the rest of the body, are short and relatively 
broad near the neck ; but as they increase in size this 
relation ceases, and, still growing in both dimensions, 
their quadrilateral form becomes evident about three 
feet from the head. Their average length is from nine 
to ten millimetres and their breadth six to seven milli- 
metres. Under the microscope the head is seen to pre- 
sent four prominent suctorial discs, usually pigmented, 
and between them a rounded elevation or rostellum. 



292 



PHYSICAL DIAGNOSIS. 



which is surrounded with about twenty-six hooklets of 
different sizes. The sexual apparatus first becomes visi- 
ble about a foot from the head. The uterus is but little 
branched, and the genital pores are situated somewhat 
behind the middle of each segment. The eggs are 





Fig. 86. 



Fig. 87. 



Fig. 86 —Head of Taenia Solium, x About 40. 

Fig. 87— Head and Proglottides of Taenia Mediocanellata. A, head, X 
B, mature proglottid, showing general apparatus; C, head and fragments of 
proglottides, showing gradual tapering of the neck. Natural size. 



about 15 * 
immature 



nearly spherical, 0.036 millimetre long by 0.03 milli- 
metre wide. The outer covering or shell has radiating 
lines. When fully formed, hooklets can be demon- 
strated on the embryo. 

Taenia Mediocanellata or Saginata. — This para- 
site is longer than the taenia solium, attaining to twelve 
or fifteen feet, and its segments are also longer. The 
head is surrounded with four large and usually black 



FAECES. 



293 




pigmented suckers, but it is not provided with a rostel- 
lum and is without a circle of hooklets. The segments 
increase in length more gradually than the taenia solium 
and are commonly pigmented. The uterus is very much 
branched, and the genital pore is situated at the side of 
the proglottis. The eggs are slightly more oblong than 
those of the solium, and exhibit a primordial yolk mem- 
brane. The embryo does not show hooklets. 

Bothriocephalic Latus. — This worm attains a 
length of fifteen to twenty-four feet. 
The head is ovoid and two millimetres 
long by one millimetre broad. It is 
cleft and provided with two lateral 

suckers, placed on either 

side of the middle line. It 

has no hooklets. The pro- 
glottides are at first short 

and small. They increase 

in breadth as they proceed, 

and towards the end of the 
approach the 

square form. The uterus 
of mature proglottides containing eggs 
exhibits a retiform arrangement and 
appears superficially as a small rosette. 
This uterine rosette is characteristic 
of this parasite. The eggs are oval, 
0.7 millimetre long by' 0.045 milli- 
metres broad; the shell is brown, and 
one end is small, opening with a lid. 
The protoplasm of the egg is divided 
into small masses of uniform size. 



Fig. 88.— Egg 
of Bothrioceph- 
alus Latus i, 
Lid. (After 

summe.r, in parasite 

" Real Encycl.") 





Fig. 89.— A, Head 
and anterior end of 
strobile of Bothrio- 
cephalus latus; B, head 
o f Bothriocephalic 
latus enlarged ; C, por- 
tion of pregnant links 
o f Bothriocephalus 
latus. (After Summer, 
in " Real Encycl." 



294 



PHYSICAL DIAGNOSIS. 



Oxyuris Yermicularis [Common Thread Worm or 
Teat Worm). — The female is ten millimetres in length, 
and exhibits two fully developed uteri which extend 
symmetrically backwards from the vaginal orifice. The 
male is rather less than half the length of the female, 
and its tail is provided with six pairs of papillae. The 
heads of both sexes are similar. It displays a remarkable 







A — -fi 

Fig. 90. Fig. 91. 

Fig. 90.— Oxyuris Yermicularis. A, Female; B. male. 

Fig. 91.— Eggs of Nematode Worm. A, Eggs of Ascaris lumbricoides, X about 300. 
B, eggs of Oxyuris vermicularis, X about 250. 

cuticular enlargement and small prominent lips. The 
eggs are irregularly oval, and measure 0.05 millimetre 
by 0.02-0.03 millimetre. The shell is membranous and 
consists of two or three laminae. Their contents are 
coarsely granular. The eggs often contain an embryo 
w T ith an indistinct alimentary canal and a tail equal 
to half the entire length. 

Ascaris Lumbricoides (Common Round Worm). — 
This is a cylindrical worm of some size, with a body that 
tapers from before backwards. The male is two hun- 
dred and fifty millimetres and the female four hundred 
millimetres long. The head, which is distinct from 
the body, consists of three conical prominences (lips) 
furnished with tactile papillae and minute teeth. The 
caudal process of the male is folded hook-like on the 



F^CES. 



295 



abdominal surface, and is provided with papillae. In 
the female the vulva lies deeply behind the anterior 
third of the body. The eggs are nearly round and 
brownish-yellow in color. Their diameter is 0.06-0.07 




Fig. 92.— Ascaris Lumbricoides. About half natural size. A male; B, female. 
(After Peris. ) 



millimetre. In the fresh state they are covered ex- 
ternally with an albuminous layer, and beneath this is 
a tough shell, which in turn encloses the very granular 
contents. 



MECHANICAL AIDS TO 
DIAGNOSIS. 



LESSON XIX. 

MECHANICAL AIDS IN THE DIAGNOSIS OF THE DISEASES 

OF THE RESPIRATORY AND VASCULAR ORGANS — 

STETHOSCOPE — STETHOMETER — CYRTOMETER — 

CARDIOMETER — LARYNGOSCOPE— 

SPHYGMOGRAPH. 

I will now briefly describe the different instruments 
which may be employed as aids in physical diagnosis, 
and give some rules to guide you in their use. 

Stethoscope. 

In the diagnosis of diseases of the respiratory and vas- 
cular organs, a stethoscope is not only often convenient, 
but at times absolutely essential. A great variety of 
stethoscopes has been devised, each inventor claiming 
for his own instrument some superiority in principle 
or shape. They may all be referred to two general 
classes, viz., flexible and solid. For general use I would 
recommend the binaural stethoscope devised by the late 
Dr. Cammann, of this city. It has two flexible tubes 
fitted into the cup that is applied to the surface. These 
are continuous with two metal tubes so curved that 
they fit into each ear, and are connected with each other 
by means of a metal bar with a toggle joint in its cen- 
tre. An elastic band holds them in position (see Fig. 
93). 

It requires some practice to become adepts in its 
use. But, once accustomed to it, you will find it has 



300 



PHYSICAL DIAGNOSIS. 



no superior. It closes both ears to all but the desired 
sounds. 

In selecting a stethoscope you should be careful that 
the ear pieces exactly fit your ears. If they are too 
large, they will cause pain ; and if too small, they will 





Fig. 93.— Stethoscope. 



Fig. 94.— Phonendoscope. 



produce a roaring noise which will obscure the sounds 
you desire to examine. 

In cardiac auscultation, and in determining abnor- 
malities of the blood-vessels, this instrument will be 
found almost indispensable ; for pulmonary auscultation 
it is only occasionally of service. 



STETHOMETER. 



301 



The phonendoscope as invented by Bianchi and Bazzi 
is an instrument devised for the same purposes as the 
stethoscope. It increases the intensity of the sounds, but 
gives them a metallic character. It can be used over 
clothing where a stethoscope is useless. It consists of a 
drum or cylinder (B), one surface of which, covered with 
a thin sheet of hard rubber is applied to the surface to 
be examined. The rubber tubes and ear pieces are at- 
tached to the opposite sides. A second rubber disk fits 
over the first, and is for the attachment of the rod (A) 
used when small areas are to be auscultated. This di- 
minishes the intensity of the sound, but is necessary for 
small areas. 

Stethometer. 



The simplest way to ascertain the circular measure- 
ment or amount of motion of the chest or abdomen is 
by means of an ordinary pocket tape. 
But Dr. Quain has devised an instru- 
ment for this purpose, called the 
stethometer. 

It consists of a brass box with a 
dial, and an index which is moved by 
a rack attached to a silken cord. 
One revolution of the index indicates 
an inch of motion, the intervening 
space being graduated, as shown in 
Fig. 95. 

It may be employed when the patient is in a standing, 
sitting, or recumbent posture. The mode of its appli- 
cation is as follows : Place the box on the sternum with 
the index pointing to the median line ; carry the silken 




Fig. 95. -Stethometer. 



302 



PHYSICAL DIAGNOSIS. 



cord around the chest to the spines of the vertebras, 
where it should be held firmly with the thumb or finger. 

The amount of motion of the side under examination, 
from the end of an expiration to the end of a full inspi- 
ration, will be accurately shown by the index. 

This instrument is of great utility in determining the 
exact amount of difference in the expansion of the two 
sides of the chest, as well as for determining the amount 
of local expansion in any region. 




Fig. 96. — Cyrtometer. 



Cyrtometer. 

It frequently happens that the exact shape of the 
chest or abdomen is far more important than the amount 
of motion. An instrument to determine this was made 
in 1860 by G. Tiemann & Co. from suggestions given 
them by Prof. Austin Flint. It resembles in principle 
the cyrtometer of Woiller, invented in 1857. ' 
1 Vide Gazette des Hopitaux, 1857, p. 134. 



CARDIOMETER. 303 

It consists of an ordinary compass with short arms ; 
slits are made in the ends of these arms to receive nar- 
row strips of lead, which are made long enough to en- 
circle the chest and meet in the median line in front ; 
they are fastened into the arms of the compass by 
means of thumb screws. An indicator is attached to 
the centre of one arm, and slides through the other ; 
this is arrested at any point by means of a thumb screw 
(Fig. 96). 

When applied, the arms of the compass are pressed 
on each side of the vertebral column and fastened by 
means of the thumb screw pressing on the indicator ; 
the strips of lead are moulded so as to fit any depression 
or elevation of the chest ; the thumb screw is then loos- 
ened and the instrument removed. After its removal, 
bring the arms of the compass together until they reach 
the same notch in the indicator as when the instrument 
was applied to the chest; fasten it with the thumb 
screw, place it upon paper, and you can easily trace the 
exact shape of the chest. 

Cardiometer. 

The cardiometer was devised by the late Dr. Cam- 
mann to determine accurately the distance of the apex 
beat from the median line. It resembles a pocket knife 
in shape, with one extremity rounded and the other 
slightly pointed. On its handle is a scale of inches 
which may be used as an ordinary rule. Enclosed in 
the handle is a graduated blade, which runs its whole 
length and is attached by a pivot to the rounded ex- 
tremity. This blade is pointed at its free extremity 
and has a slit through its centre. A small arm is con- 
nected to one side of the handle, by means of a pivot, 
near its rounded extremity ; the free end slides along 



304 



PHYSICAL DIAGNOSIS. 



the slit in the blade and has a small indicator attached 
to it. As the instrument is opened the indicator marks 
the number of inches between the extremity of the 
blade and the extremity of the handle (see Fig. 97). 

In using this instrument, place the pointed extremity 
of the handle on the median line and open the blade to 




Fig. 97. — Cardiometer. 

a point corresponding to the apex beat. By reading the 
scale, the distance of the apex beat from the median 
line is determined. 

In recording cases, and in accurately determining 
slight changes in the position of the apex beat, this 
instrument will be found of service. 



Laryngoscope. 

The apparatus consists of three parts — the throat 
mirror, the head or reflecting mirror, and the source of 



G. TIE MANN = CO 




Fig. 93.— Laryngeal Mirror. 

illumination. It is used to examine the nose and upper 
air passages. 

The throat or laryngeal mirror is a small mirror 



LARYNGOSCOPE. 



305 



mounted in a German -silver frame and attached to a 
delicate handle from six to seven inches long. It is 
made in six sizes, varying from three-eighths of an inch 
to one inch in diameter. There are several different 
shapes, but the round mirror is best adapted to general 
purposes. For laryngoscopic work the mirror is attached 
to the handle at an angle of 135° ; for rhinoscopic, at an 
angle of 105°. 

The reflecting mirror is a large concave mirror, perfo- 
rated in its centre so that the 
illuminating and visual rays 
will be in the same axis. It 
should not be too large, or its 
weight will become objection- 
able. The mirror is attached 
to a head band by means of a 
ball-and-socket joint, to give 
perfect freedom of motion. 

Source of Illumination. — 
Sunlight is to be preferred 
because of its whiteness, but 
the Argand burner or a coal- 
oil lamp may be used. Sajous 
states that a small piece of 
camphor dissolved in the oil 
will make the light whiter. A condenser may be used 
to increase the intensity of the light. 

Method of Examining the Larynx. — So adjust the 
reflecting mirror that the opening in its centre corre- 
sponds to the line of vision, and that the light is thrown 
into the patient's mouth. Then direct the patient to 
catch the tip of his tongue in a napkin and draw it well 
forward. Take the throat mirror, previously warmed 
over the lamp (to prevent the condensation of moisture 
20 




Fig. 99.— Head Mirror. 



306 PHYSICAL DIAGNOSIS. 

on its surface), lightly in the right hand, and introduce it 
into the back of the throat with its face directed down- 
ward. It should not touch the base of the tongue, or 
retching may be excited. Let the posterior surface of 
the mirror rest against the base of the uvula, and push 
it upward and backward toward the vault of the pha- 
rynx. The plane of the mirror should form an angle 
of about 45° with the horizon. 

If the throat is irritable, the mirror should be removed 
and the patient allowed to rest a few minutes before 
another attempt at examination is made. It may be 
necessary to produce local anaesthesia by means of a ten- 
per-cent solution of cocaine ; but this procedure is to be 
avoided, as a sense of choking is thereby produced. The 
administration of a small dose of potassium bromide a 
few hours previous to the examination will be found of 
service in rendering the parts less irritable. 

Laryngoscopical View of the Larynx in a Nor- 
mal Condition. — In the laryngeal mirror, when it has 
been introduced into the pharynx as already directed, 
the first thing that comes into view is the back of the 
tongue with its large follicles, then the hoUow space be- 
tween it and the anterior or glossal surface of the epi- 
glottis, which is of a dark-pink color. 

Next, the apex and laryngeal surface of the epiglottis, 
the free surface being of a yellow color, while the laryn- 
geal or under surface is invariably of a bright-red color. 

Next, the ary -epiglottic folds, which are of about the 
same color as the mucous membranes of the gums. 

Next, the ventricular bands, having about the same 
color as the mucous lining of the lips. 

Next, the vocal cords, which are pearly white, like the 
sclerotic coat of the eye. 

Next, the tracheal rings, which are of a decidedly 



RHINOSCOPY. 307 

yellow color, the mucous membrane between them being 
of a bright red. 

Lastly, the bifurcation of the trachea and the bronchi. 

In making your laryngeal observations, as soon as the 
posterior wall of the larynx is brought into view, note 
carefully the form, size, color, position, and mobility of 
the true and false vocal cords, as well as all their rela- 
tions and form of motion, also the appearance of the 
anterior wall of the larynx from the free border of the 
epiglottis down to the trachea. 

For the purpose of investigating the action of the 
vocal cords, the patient should be directed to inspire 
deeply or to produce a vocal sound, as ah or eh. 

You must remember that the objects seen in the laryn- 
geal mirror are reversed : the anterior part of the larynx 
becomes the posterior ; but the right side remains the 
right, and the left remains the left. This reversed pic- 
ture is somewhat troublesome to the beginner. By fre- 
quently examining the different parts in the order al- 
ready given, you will become familiar with their normal 
appearance and motions, and be prepared to recognize 
abnormalities. 

The laryngeal diseases in which the laryngoscope is 
of special service as an aid in diagnosis, are thickening, 
induration, and ulcerations of the vocal cords, paralysis 
of the vocal cords, polypi or malignant growths spring- 
ing from any portion of the larynx, exudation on the 
mucous surface of the epiglottis or larynx, follicular en- 
largements, and ulcerations of the larynx, as well as 
other changes which may occur in the course of chronic 
laryngitis or tracheitis. 

Rhinoscopy. 
The examination may be made through the anterior 



308 



PHYSICAL DIAGNOSIS. 



or posterior nares, and is called, accordingly, anterior 
or posterior rhinoscopy. The anterior examination is 
by far the more satisfactory. 

Anterior Ehinoscopy.— Dilate the nostril by means of 
a nasal speculum (Fig. 100), and throw the light from the 
reflecting mirror into the cavity. By placing the fingers 
of the left hand on the forehead of 
the patient, and pressing the tip 
of the nose upward with the 
thumb, the opening is much en- 
larged. The head of the patient 
should be on a level with that of 
the examiner. Inspect the infe- 
rior meatus first. Then, by turn- 
ing the head of the patient slightly 
from side to side, the surface of 
the septum and that of the inferior 
turbinated body will be brought 
successively into view. Now tilt 
the head backward until the mid- 
dle turbinated body is seen, and 
examine its surface and that of 
the septum opposite. By further 
tilting, the anterior end of this 
body and the vestibule of the nose 
can be seen. 

A ten- or twenty-per-cent solution of cocaine is now 
thrown into the cavity, and, after allowing sufficient time 
for the contraction of the blood vessels, the same pro- 
cedure is repeated. 

Posterior Ehinoscopy. — Pass the tongue depressor 
well over the arch of the tongue and pull its base for- 
ward, depressing it at the same time. You must be care- 
ful not to crowd it back into the throat, or retching may 




y 

Fig. 100.— Nasal Speculum. 



SPHYGMOGRAPH. 309 

thereby be excited. Warm the rhinoscopic mirror and 
introduce it sidewise between the uvula and left pillar 
of the fauces. When it is well in the pharynx, with its 
face directed forward and slightly upward, turn it gently 
until the posterior nares are brought into view. 

The septum is seen in the median line separating the 
oval openings of the nares. On each side of the sep- 
tum the nasal passages appear as dark cavities. The 
superior turbinated body is visible in the upper part of 
each cavity as a faint reddish band ; below it is the 
middle turbinated body, appearing as an elongated mass 
of a yellowish-red color ; while between the two posteri- 
orly is a dark line — the superior meatus. Passing further 
downward you come to the middle meatus and the in- 
ferior turbinated body, only the upper half of which can 
be seen. It appears to rest on the floor of the nose. 
The inferior meatus cannot be brought into view. 

By turning the mirror to the side, the opening of the 
Eustachian tube may be seen as a dark slit. If the 
handle of the mirror be raised, the vault of the pharynx 
is brought into view. It presents an irregular surface, 
indicating the site of the pharyngeal tonsil. 

These various parts making up the complete image 
can be seen only in detail. 

This examination discloses the condition of the nasal 
mucous membrane, and such morbid alterations as may 
exist there, as necrosis, ulceration, polypi, etc. In the 
vault of the pharynx one can see the condition of the 
pharyngeal tonsil, and such hypertrophy as may be 
present. 

Sphygmog rapli . 

Various modifications of the sphygmograph have been 
devised by different experimenters, but the one which 
seems to me to be the best is that which was invented 



310 PHYSICAL DIAGNOSIS. 

by M. Marey, of Paris, to determine various points in 
the physiology of the circulation of the blood. 

Tliis instrument consists of a brass frame with a wing 
fastened to each side by hinges, so as to spread out upon 
the arm when the instrument is applied. Ed closed in 
this frame is a flexible steel spring, covered od the under 
surface of its free extremity with an ivory button, which 
rests upon the artery or vein to be examined, and is con- 
nected by means of a bar of metal, which has a vertical 
plate attached to it, with a very light lever moving upon 
a pivot ; the vertical plate is brought in contact with the 
lever by means of a screw. The free extremity of the 
lever registers its movement up a blackened strip of 




Fig. 101.— Marey's Sphygmograph. 

paper that covers the brass plate. This plate is moved 
at a uniform rate by means of watchwork placed in the 
small box beneath. Ten seconds are occupied in the 
passage of the plate. A thumb screw winds up the 
watchwork, and a small lever starts the plate or stops 
it, as desired. Silk bands embrace the arm and hook on 
to projecting points on each wing, as seen in Fig. 101. 

The sphygmograph was proposed as an aid in the 
diagnosis of diseases of the heart, arteries, and veins. 
When properly adjusted, it is claimed that it gives an 
exact representation of the pulse curve, the frequency 
and regularity of the pulsations, and any peculiarity of 
the pulsation. But it has not fulfilled the expectations 
that were entertained of it, for it has been found that 



SPHYGMOGRAPH. 311 

the characters of a sphygmogram may be entirely 
changed by merely altering the amount of pressure on 
the arterial wall. During the excitement, too, which 
is sometimes brought on by adjusting the instrument, 
the tracing obtained is very different from that taken 
when the heart is beating tranquilly. 

Sphygmograms are of more importance in the record- 
ing of cases and clinical teaching than in diagnosis. By 
means of them we can demonstrate elements of the 
pulse that would otherwise escape detection. 

Care must be used in adjusting the instrument, for if 
too much pressure is made the arterial wall will be so 
compressed as to interfere with its free movement ; and 
if the pressure be too slight the full movement of the 
wall will not be registered. In taking a tracing from 
the radial artery, the instrument should be applied to 
the arm with the ivory button resting on the artery just 
beyond the lower extremity of the radius. 

The pulse is a wave of increased arterial pressure, 
started by the systole of the heart, and passing over the 
arteries of the body. A graphic record of this wave, 
taken at any point of an artery, is called a pulse curve. 
It consists of three parts — the upstroke or anacrotic 
limb, the crest, and the down-stroke or katacrotic 
limb. 

The upstroke represents the flow of blood into the 
arteries and the consequent distention of their walls. 
It is nearly synchronous with the ventricular systole. 

The crest of the pulse curve designates the period dur- 
ing which the artery reaches its greatest degree of dis- 
tention and begins to recoil. It is usually pointed, but 
may be rounded, as in certain aneurisms and aortic 
stenosis (see Figs. 105 and 109). 

The doivnstroke represents the return of the artery 



312 



PHYSICAL DIAGNOSIS. 



to its original calibre. Its descent to the base line is 
gradual. It is broken by one or more undulations, the 
most prominent of which is the dicrotic crest. This 
crest is sometimes so marked as to be perceptible to the 
finger, giving rise to the dicrotic or " double "pulse. 




Fig. 102. — Normaltracing. (After Bramwell.) 

The up-stroke is from a to 6. 

The crest is at b. 

The down-stroke is from b to a', with c the predicrotic, and d the dicrotic crest. 

In a normal pulse curve the up-stroke is nearly or 
quite vertical, the crest is pointed, and the down-stroke 
slopes gradually to the base line. The predicrotic and 
dicrotic crests are visible on the down-stroke (see 
Fig. 102). 




Fig. 103.— A Dicrotic Pulse Tracing. (After Eichhorst.) 

Dicrotism is favored by a low arterial tension, a suf- 
ficiently powerful heart, elasticity of the vessel walls, 
and a diminished resistance in the small arteries. It 
occurs in cases where there is loss of vaso-motor tone, 
and in typhus and typhoid fevers. 

The prominent features of the tracing of aortic re- 
gurgitation are the suddenness of the down-stroke and 
the almost complete absence of the dicrotic crest (Fig. 104 ) 



SPHYGMOGKAPH. 



313 



In aortic stenosis (Fig. 105) the blood is not propelled 
into the artery suddenly, owing to the resistance it meets, 




Fig. 104.— Pulse Tracing in Aortic Regurgitation. (After Striimpell.) 

and hence the up-stroke is gradual. The crest in this 
instance is rounded. 

If atheroma is sufficiently advanced to cause much 
impairment in the elasticity of the arterial walls, the 



Fig. 105.— Aortic Stenosis. (After Bramwell.) 

tracing will be as represented in Fig. 106. Owing to 
slowness of expansion the up-stroke is gradual. The 
crest is rounded in this case, though it may sometimes 




Fig. 106.— Tracing from a Case of Atheroma. (After Eichhorst.) 

be pointed. The loss in elasticity prevents the occur- 
rence of secondary crests. 

The frequency of the pulse may also be studied by 



314 



PHYSICAL DIAGNOSIS. 



means of the sphygmograph. As the plate moves at a 
given rate of speed, the number of poise curves traced 
during its passage indicates the number of heart beats 
in a given number of seconds. ' 

Fig. 107 is a tracing from a case of mitral regurgita- 
tion with a rapid pulse. It will be seen that the pulse 
curves follow each other in quick succession. 



Fig. 107.— Frequent Pulse (120 to 130). (After Bramwell.) 

The pulse may be irregular in time or volume, or in 
both. Irregularities in volume are usually associated 
with irregularity in time. 



Fig. 108.— Mitral Obstruction. (From a patient in Bellevue Hospital.) 

In Fig. 10S, from a case of mitral obstruction, irregu- 
larity both in time and volume is represented. 



Right Arm. 



Left Arm. 
Fig. 109. — Aneurism of Ascending Aorta. (From a patient in Bellevue Hospital.) 

The passage of the blood through an aneurismal sac 
usually leads to a flattening of the pulse curves (see 
Fig. 109) and a retardation of the pulse on the corre- 
sponding side. 

1 Mahomed's modification, of Marey's sphygmograph is so con- 
structed that four inches of the plate pass by the point of the pen in 
ten seconds. 



LESSOR XX. 

MECHANICAL AIDS IN THE DIAGNOSIS OF DISEASES OF THE 
NERVOUS SYSTEM, AND IN GENERAL DISEASES— OPH- 
THALMOSCOPE — THERMOMETER — MICROSCOPE — 
DYNAMOMETER — ^STHESIOMETER — EX- 
PLORING TROCAR — SPECULA. 

Ophthalmoscope. 

The simplest and least expensive ophthalmoscope is 
Liebreich's. ] It consists of a concave circular mirror 
about one and one-half inches in diameter, and from ten 
to twelve inches focal distance, perforated in the centre 
by a small circular aperture. Behind the mirror is a 
hinged clip, into which eye pieces may be adapted, three 
of which are concave and two are convex, from six to 
twelve inches focal distance. On the side of the mirror 
is a shank which fits into a handle about six inches in 
length, by which the mirror can be held in any position 
desired. In addition to these there is a convex object 
lens of two and one-half inches focus (shown in Fig. 110). 

The examination is best made in a darkened room, the 
examiner and patient sitting or standing face to face. 

1 The best instrument for the direct method of examination is that 
of Dr. Loring, of this city. The refraction of the eye examined 
may be determined by its use, it having a complete series of convex 
and concave glasses, which, by an ingenious revolving disc ar- 
rangement in the mirror, may be placed before the eye of the ob- 
server. The student who desires to give much attention to ophthal- 
moscopy will probably prefer this instrument, although it is more 
expensive than that of Liebreich. 



316 PHYSICAL DIAGNOSIS. 

There are two methods of examining the eye with this 
instrument, the direct and indirect. In both a lamp is 
placed at the side and a little behind the patient's head, 
the flame being on a level with his eyes. The handle of 
the mirror is held between the thumb and forefinger, 
and the eye piece at the aperture of the mirror is 
brought close to one of your own eyes in such a manner 
that the light from the lamp is reflected into the eye 
under observation. If you desire to make a direct ex- 
amination, bring your eye which is armed with the mir- 
ror very close to the patient's eye, at the same time ad- 
justing your eye for objects at an infinite distance, that 
is to say, having the accommodation at rest. The ex- 




TIEMANN &Cff. 

Fig. 110.— Liebreich's Ophthalmoscope. 

aminer should use the corresponding eye in examination 
with the one being examined. If the eye of the observer 
and that of the patient be of normal length, a clear 
image will be obtained ; if not, the proper correcting 
glass, convex or concave, may be used. The patient 
should turn his eye a little outward and across the room 
upon some object. 

In indirect examinations the lamp and mirror are ar- 
ranged the same as for the direct, but the mirror is only 
brought sufficiently near the eye to be examined to 
bring the focus of the reflection upon the optic disc ; 
having done this, take the convex lens between the 
thumb and first finger of the hand not engaged with the 
mirror ; rest the second and third fingers of this hand 



OPHTHALMOSCOPE. 317 

on the patient's forehead, so as to steady the lens, and 
move it to and fro directly in front of the eye under 
examination until you find the focus — your little finger 
remains free to raise the lid, if necessary, or to press 
upon the eyeball. 

When by practice you have acquired dexterity in 
manipulating this instrument, and by repeated examina- 
tions of the normal eye have become . familiar with the 
appearance of the normal retina, optic disc, and choroid, 
you will be able readily to recognize many of the patho- 
logical changes in those structures which are now be- 
coming important elements in the diagnosis of diseases 
of the brain, spinal cord, and other vital organs. 

The importance of this instrument in the diagnosis of 
diseases of the eye is universally admitted, so that no 
ophthalmic surgeon of the present day regards the ex- 
amination of an eye complete without an ophthalmo- 
scopic examination. I shall not attempt to detail its 
diagnostic uses in this branch of surgery, but will 
briefly state its uses in medical diagnosis, as it is com- 
ing to be regarded of no little importance. 

An ophthalmoscopic examination of an eye may show 
the optic disc to be the seat of simple hypercemia, ance- 
mia, ischcemia, or congestion and effusion within and 
around it ; of inflammation of its sheath or of its sub- 
stance ; and, lastly, of atrophy. 

It may show the retina to be the seat of hypercemia, 
anaemia, of fatty exudation patches, or of haemorrhages. 

It may show the choroid to have partially or alto- 
gether lost its pigment and to be the seat of haemor- 
rhages, to have undergone atrophy, etc. 

It may show the blood vessels within the eye di- 
minished, obstructed, dilated, tortuous, varicose, pulsat- 
ing, or to be the seat of embolism, thrombosis, or rupture. 



318 PHYSICAL DIAGNOSIS. 

Hyperemia of the Disc may occur in the vessels of 
the disc, in the retinal veins, or in both retina and pa- 
pillae together. The larger vessels, and chiefly the ret- 
inal veios, are seen dilated, darker in color than natu- 
ral, slightly tortuous, or even varicose. 

To pronounce upon slight hyperemia of the disc or 
retina is a delicate and difficult task ; generally the 
hyperaemia is to be first seen on the inner half of the 
disc. In states of hyperaemia, when pressure is made 
on the ball of the eye, pulsations in the veins are more 
marked than in the normal condition. Direct exami- 
nation is important in these cases. 

Clinical Significance of Hyperaemia of the Disc or 
Retina. — Its causes are many. First, it is frequent in 
the first stage of ischaemia, of neuritis, or of an atrophic 
process. It may be due to orbital disease, to choroi- 
ditis, to Bright's disease, to alcoholismus, to cerebral 
tumors, to acute or chronic meningitis, and to active 
cerebral hyperaemia ; transient hyperaemia may be seen 
in forms of cardiac disease which obstruct the venous 
circulation, and in Grave's disease. 

Anemia of the Disc and Retina is the opposite of 
hyperaemia. It is always accompanied by anaemia of 
the retina and choroid. It is liable to be mistaken for 
atrophy of the disc ; but the edges of the disc are not 
so sharp and well defined as in atrophy, and it is pos- 
sible to distinguish the arteries from the veins ; again, 
anaemia is equal in both eyes, atrophy is not ; besides, 
atrophy rarely involves a whole disc equally, as does 
anaemia. 

Clinical Significance. — The causes of anaemia of the 
disc or retina are the same as those of general or local 
anaemia. 

Ischemia of the Disc is a mechanical venous conges- 



OPHTHALMOSCOPE. 319 

tion, oedema, and punctate extravasation of the disc ; 
the disc is swollen, rising abruptly on one side and sink- 
ing gradually on the other ; its color varies from a bright 
transparent gray to a dirty red ; the margin of the disc 
is wholly concealed by infiltration and excessive vascu- 
larity, which gives it a mossy appearance ; the veins of 
the retina are tortuous — they may be very tortuous. 

It is difficult and sometimes impossible to distinguish 
this condition from optic neuritis ; the two are fre- 
quently associated. 

Clinical Significance. — The causes of ischsemia of the 
disc are all those changes within the skull which more 
or less directly distend the ophthalmic veins. The three 
main causes are, chronic meningitis, hydrocephalus, and 
tumors. 

The lesions of the optic disc which seem to have the 
closest connection with cerebral, spinal, and general 
diseases are hypercemia and anaemia of disc and retina, 
optic neuritis with its consecutive atrophy, and primary 
or progressive atrophy. 

In Optic Neuritis the disc becomes larger than usual, 
its edges indistinct, irregular, and puffy, the infiltration 
casting a veil over it, so as to change its color into a 
lilac gray, and more or less to conceal the vessels as 
they pass within its margin. The veins increase in 
size, become tortuous or even varicose ; they darken in 
color and seem to be gorged with blood. The capilla- 
ries, which in their normal state ought not to be seen, 
also become evident, and give a mossy or woolly ap- 
pearance to the disc (Von Graefe). 

Clinical Significance. — Optic neuritis is very gene- 
rally coexistent with meningitis at the base of the 
brain, with cerebral tumors and large cerebral luvmor- 
rhages. 



320 PHYSICAL DIAGNOSIS. 

It can only be distinguished from the retino-neurit is 
of albuminuria, and from the retino-choroiditis of 
syphilis, by the history of the case, by its limitation for 
the most part to the papillae and the conveying vessels. 
Its resemblance to ischaemia has already been stated. 

In the consecutive atrophy of optic neuritis, the in- 
tense vascularity in and about the disc subsides, the in- 
filtrations are absorbed, the nerve whitens, and the 
capillaries slowly shrivel and vanish. The edges of the 
disc become distinct but are deformed, and patches of 
organized lymph are to be seen upon and about them. 

In progressive atrophy of the optic disc, the fine ca- 
pillaries which give the rose tint to the healthy disc 
slowly disappear, and a dead or pearly white is left. 
The border of the disc is sharp, clearly defined, flat, and 
even. 

This lesion generally depends upon some disease of 
the cerebrum, cerebellum, or spinal cord. 

The most important indications of organic disease ca- 
pable of being recognized by an ophthalmoscopic exami- 
nation of the eye have been summed up by Dr. T. C. 
Allbutt as follows : 

In the first stage of meningitis there is dilatation of 
the veins of the retina, peripapillary congestion, and 
often external effusion. In the second stage the veins 
become tortuous, thrombotic, and sometimes rupture. 

In basilar meningitis optic neuritis is present, but not 
in meningitis of the convexity. 

Intercranial affections which directly distend the 
ophthalmic veins, as hydrocephalus and intracranial 
tumors, cause ischaemia of the discs, and, if the pres- 
sure is extreme, atrophy of the optic nerves. 

Acute and chronic cerebral softening causes acute or 
chronic optic neuritis and atrophy. Cerebral haemor- 



THERMOMETER. 321 

rhage, when large, by its obstruction causes stasis in 
the vessels and effusion in and about the optic disc. 

In diseases of the spinal cord, as progressive atrophy, 
sclerosis, and chronic myelitis, simple progressive atro- 
phy of the optic disc is not uncommon. 

In Brighfs disease the nutrition of the optic nerve, 
as well as that of the retina, is interfered with ; upon 
the retina extravasations are seen in the course of the 
vessels ; these extravasations are slowly effused and 
pass into degenerative states, forming white patches or 
striations along the margins of the veins ; most of these 
patches have evidently been clots ; some may be due to 
the degeneration of retina. 

In syphilis the choroid is the chief seat of lesion, and 
patches of many colors are to be seen at the back of 
the eye ; some of brilliant white and others of darker 
tints, as red or brown. We also have intense neuro- 
retinitis in syphilis, but its appearances cannot positively 
be distinguished from those of any other forms of neuro- 
retinitis. 

Thermometer. 

The thermometer is now regarded an indispensable 
mechanical aid in the diagnosis of disease. I prefer (and 
would recommend to you) the straight, self -register nig 
clinical thermometer represented in Fig. 111. 

This thermometer consists of a glass stem, having on 
it a graduated scale varying from 95° to 112° F., ex- 
hibiting .2° F. The upper extremity of the stem is 
closed. At the lower end there is a bulb of mercury as 
thick as the diameter of the stem. Within the stem is a 
bit of mercury, detached from that in the bulb, called the 
index ; this index is set by taking the bulb and stem of 

the instrument firmly in the hand, when, by repeated 
21 



122 



PHYSICAL DIAGNOSIS. 



sudden blows of the wrist upon the knee, the index is 
brought down the stem to a point just below the lines 
^ which indicate the degrees. After the in- 
dex has thus been set, the bulb of the instru- 
ment may be applied to the axilla, between 
the thighs, in the mouth, rectum, or vagina. 
or to any part where it can be completely 
covered. 1 When the instrument has been in 
perfect contact with the parts for five or 
seven minutes, gently remove it, and the top 
of the index will denote the maximum tem- 
perature of the part. (Thermometers are now 
made with very small bulbs requiring but a 
minute's contact.) 

If the axillary temperature is to be taken, 
the axilla should first be thoroughly dried, 
and the bulb of the instrument placed directly 
beneath the fold of the pectoralis major mus- 
cle, the forearm on that side being carried 
across the chest, and the elbow held by the 
other hand of the patient or by an assistant. 
If the rectal or vaginal temperature is to be 
taken, the parts should first be thoroughly 
cleansed with warm water, and the patient 
placed on the side. 
The mouth is the usual place at which the temperature 
is taken, and is sufficiently accurate for relative values. 



Fig. ill.— 

Straight. Self 

Registering 

Thermometer. 



1 Dr. E. Seguin, of this city, lias devised a thermometer for de- 
termining localized surface temperatures. The peculiarity of this 
instrument is that the mercurial bulb is flattened, so as to furnish 
a large surface at its base. Dr. Seguin claims for this instrument 
facility and accuracy in determining the surface temperature of 
different parts of the body. 



THERMOMETER. 323 

Thermometrical observations, if possible, should be 
continuous, and be taken at least twice in the twenty- 
four hours — from 7 to 9 a.m. and from 4 to 7 p.m. 

In cases of doubtful diagnosis, and in very active dis- 
ease, they also should be taken at noon and at midnight. 

The pulse and number of respirations should be noted 
at the time the temperature is taken. The rate of rise 
in the temperature indicates the degree of heat, and 

should be noted. 

\ 

Range of Temperature in Health. — The normal 
temperature, taken in any of the above-mentioned local- 
ities, varies from 97.5° F. to 98.4° F. Any rise above 
99.5° F., or depression below 97.3° F., if persistent , is a 
sure index of disease. A temporary elevation takes 
place after meals and after violent exercise. 

But there is a diurnal variation of temperature 
amounting to one degree usually, sometimes two. The 
minimum occurs between 2 and 6 in the morning, and 
from that time there is a rise until the maximum is 
reached between 5 and 8 in the evening. 

Eanges of Temperature in Disease. — The greatest 
range of temperature in disease is 17.0° F. ; the minimum 
of 91.8° F. has been recorded with recovery of the pa- 
tient, and the maximum 117.8° F. The highest recorded 
temperature was observed in the New York Hospital in 
a patient with sunstroke. The highest temperature ordi- 
narily met with in severe and fatal cases rarely exceeds 
108° F., except in sunstroke, in which 115° F. has oc- 
curred with recovery. 

A single thermometrical observation is an important 
element in differential diagnosis when taken in connec- 
tion with other symptoms, but it has no independent 
diagnostic value. 



324 PHYSICAL DIAGNOSIS. 

Axillary temperature below 100° F. excludes the ex- 
istence of fever ; above 101° F., leads to the probability 
of fever; when it exceeds 108° F., you may probably 
exclude fever. 

A temperature of 107° F. indicates malignancy, and 
when met with for two consecutive days in typhus, 
scarlatina, measles, pneumonia, pyaemia, meningitis, or 
rheumatic affections, death is almost certain to follow. 
In relapsing and in pernicious intermittent fevers, the 
temperature may rise to 107° without indicating great 
danger. 

In many diseases, during the last few hours of lif e, the 
temperature suddenly rises as high as 109° F., or even 
112° F. ; especially is this true in tetanus, sunstroke, 
typhus, pyaemia, etc. A temperature below 98° does 
not necessarily indicate collapse, but is more likely to 
be met with in the aged and feeble when subjects of 
grave disease. 

Thus it is evident that a given temperature without 
its antecedents is apt to mislead in diagnosis. When 
isolated, the highest temperature only portends danger, 
and with a temperature of 95° F. collapse is not cer- 
tain. 

Daily Variation of Temperature in Disease. — 
Daily thermometrical variations in disease depend upon 
the elements which constitute the morbid processes, the 
intensity of these processes, and the stage they have 
reached; also somewhat on the idiosyncrasy of the 
patient. 

A single day's variations may determine the severity 
and stage of a disease ; but you must compare the vari- 
ations of a number of days before (in a large proportion 
of cases) you can reach a diagnosis. 

High average temperature, above 104° F., is met with 



THERMOMETER. 325 

in remittent, typhus, typhoid, and relapsing fevers, in 
severe pneumonia, etc. 

A moderately high average temperature above 102° F. 
is met with in catarrhs, cerebro-spinal meningitis, diph- 
theria, dysentery, pleurisy, pericarditis, acute rheuma- 
tism, peritonitis, etc. 

A slight average rise in temperature above 100° F. 
has a varied significance, and is met with in a large 
class of chronic affections, and at the commencement of 
acute inflammations and mild types of fever. 

When your thermometrical observations follow regu- 
lar diurnal variations, with a rise each day of one de- 
gree — as, first day, morning 99.5° F., evening 101.5° 
F. ; second day, morning 100.5° F., evening 102.5° F.; 
third day, morning 101.5° F., evening 103.5° F.— you 
have almost certain evidence of typhoid fever. If the 
temperature does not exceed on any evening 103.5° F., 
the fever will probably have a mild course ; if it reaches 
105° F. in the evening, it shows that the attack is a se- 
vere one, and forebodes danger. A sudden and marked 
reduction of temperature to 95° F. during the third 
week of typhoid fever, denotes haemorrhage from the 
sloughs of Peyer's patches. 

If a patient with measles retain a high temperature af- 
ter the eruption has faded, it indicates some complication. 

Whatever differences of opinion may exist in regard 
to the importance and reliability of thermometrical ob- 
servations as elements of diagnosis, the following propo- 
sitions, it seems to me, may be regarded as established : 

1. An abnormal temperature denotes the presence of 
some disturbance in the animal economy. 

2. Certain degrees of temperature indicate fever. 

3. The height of the temperature decides the severity 
and danger of a disease. 



326 PHYSICAL DIAGNOSIS. 

4. Thermometrical observations aid us in discovering 
the laws which regulate the course of certain diseases. 

5. When the normal thermometrical course of a dis- 
ease has been determined, its diagnosis is simplified. 

6. The thermometer indicates quickly and certainly 
any deviation in the regular course of many diseases, 
the transition from one stage to another, and the com- 
mencement of convalescence. 

7. It reveals the occurrence of complications. 

8. It often reveals the imminence of a fatal termi- 
nation. 

9. It sometimes shows the impossibility of the con- 
tinuance of life. 

10. It is an important guide as regards the effects of 
remedial agents. 

Microscope. 

The compound microscope consists essentiaUy of a 
tube (T) having a system of lenses at each end ; the up- 
per system is called the ocular (Oc), the lower the ob- 
jective (Obj). Within this is a smaller or draw tube. 
The whole is attached to the stand (S). At St is the stage 
on which the object to be examined is placed. In its 
centre is a diaphragm for the purpose of regulating the 
amount of light. Below the stage a mirror (M), with a 
plane and concave surface, is suspended. It is for the 
purpose of illuminating the specimen, and is so adjusted 
as to admit of movement in any direction. The lenses are 
focussed by means of the coarse (C. adj) and fine (F. adj) 
adjustments. The coarse adjustment has a rack-and- 
pinion movement ; the fine adjustment consists of a 
finely cut screw acting against a spring. There should 
be at least two objectives— a low power having a focal 
distance of half an inch, and a high power with a focal 



MICROSCOPE. 



327 



distance of one-sixth of an inch. For bacteriological 
work a homogeneous oil-immersion lens (one-twelfth) 
is required. 

A good microscope should magnify from fifty to four 
hundred linear diameters. 

Method of Using the Mi- 
croscope. — For the exami- 
nation of blood, pus, urine, 1 
etc. (for sputum see page 
250), all that is necessary is 
to place a drop of the speci- 
men in the centre of a slide, 
cover it with a cover glass, 
and put it under the micro- 
scope. Small pieces of tumors, 
and curettings from the ute- 
rus and cervix uteri, may be 
teased out on a slide with fine 
needles and examined for their 
component cells. But when it 
is remembered that a diagnosis 
is based in many instances 
upon the arrangement as well 
as the appearance of the cells, 
it will be seen that this method 
is open to serious objections. 
Tissues should always be hard- 
ened, embedded, and cut into thin sections. The sec- 
tions should then be stained and mounted. For the 
methods of hardening, staining, etc., the student is re- 
ferred to Stirling's Practical Histology. " 




Fig. 112.— The Microscope. 



1 For obtaining the sediment from urine, it is convenient to close 
the upper end of a pipette with the finger, pass its tip down through 



the urine, and then remove the finger. 



328 



PHYSICAL DIAGNOSIS. 



Dynamometer. 

The best dynamometer is that of M. Mathieu, an in- 
strument maker of Paris. It is very simple, and for 
measuring the strength of the hands leaves nothing to 
be desired. 

It consists (as shown in Fig. 113) of an elliptical 
steel spring, to which is attached a semicircle of brass 
upon which a scale is marked. The indicator termi- 
nates at its central end in a cogwheel which works 
upon a steel arm. When it points to zero of the scale, 
the lower end of the arm touches the elliptical spring. 
A brass sheath upon the under side of the scale keeps 




Fig. 113.— Dynamometer. 

this arm in place, at the same time allowing it to move 
freely. 

When the dynamometer is grasped in the hand, and 
the two sides of the spring approximated, the indicator 
is turned by the upward movement of the arm. One 
great advantage of this instrument is that, when the 
pressure is taken off, the indicator does not return to 
zero, but remains at the point to which it has been car- 
ried by the muscular power of the individual. 

Clinically, you are able to measure the strength of 
partially paralyzed muscles of the upper extremities, 
to determine the slightest difference in the muscular 
power of the two hands, as well as to determine any 
changes that may occur from time to time in the course 
of a case of paralysis. 



^STHESIOMETER. 329 

JEsthesiometer. 

This instrument was invented by Dr. Sieveking in 
185S for the purpose of determining the degree of tac- 
tile sensibility of any part of the body. 

It consists of a graduated bar of metal four or five 
inches in length. At one end is a fixed steel point. 
Another steel point is made to slide upon the bar, and 
can be fixed at any distance from the first by a screw 
which works at the top of the slide (Fig. 114). 

It will be found that in a perfectly healthy person, 
when two impressions are simultaneously made upon 
the skin, the power of distinguishing them varies 
greatly in different parts of the body. 




Fig. 114.— ^Esthesiometer. 

The following table of Weber gives the distances at 
which the two points of the a3sthesiometer are normally 
felt in the different regions of the body : 

Mm. 

Tip of the tongue 1.1 

Palm of distal phalanx of finger 2.2 

Palm of second phalanx of finger.. ±A 

Tip of nose 6.6 

White portion of the lips 8.8 

Back of second phalanx of finger 11.1 

Skin over the malar bone 15.4 

Back of the hand 29.8 

On the forearm B9.6 

On the sternum 44-.0 

On the back 66.0 



330 PHYSICAL DIAGNOSIS. 

In using the instrument, first fix the two points at 
the distance which is normal for the part of the skin to 
be inquired into. The points must be applied simulta- 
neously. 1 If the patient feels only one point when 
both points touch the skin, the two points must be 
gradually separated from each other, and reapplied to 
the part until both points are felt ; in this way you will 
determine the amount of anaesthesia present. If, on 
the other hand, the two points are each distinctly felt at 
the normal distance limit, they must be brought gradu- 
ally toward each other until one point is felt ; thus 
you determine the amount of hyperesthesia present. 

The patient ought not to see the instrument, or know 
for what purpose it is applied. 

This instrument aids you in determining the amount 
and extent of sensational impairment in cases of paraly- 
sis, as well as for determining if the loss of sensation is 
progressive. In the record of cases it is also of service. 

Exploring Trocar. 

This instrument is an aid to positive diagnosis, as it 
enables you to determine the character of fluid contained 
in a distended pleural, pericardial, or abdominal cavity, 
or of that contained in any fluctuating tumor or deep- 
seated abscess. 

There are three instruments which may be used as 
exploring trocars, viz. : the ordinary Hypodermic Sy- 
ringe, Dieulafoy's Aspirator, and Dieulafoy's Exhaust- 
ing Syringe. 

The objection to the hypodermic syringe is that the 
needles are so small, and the exhausting power of the 

1 Care must be taken not to press too heavily, or the sensation of 
two points will be converted into the sensation of one. 



EXPLORING TROCAR. 



331 



syringe so slight, that you are not always able to draw 
the fluid through them. 

The Aspirator is the best instrument for the purpose, 
but its price places it beyond the reach of many. 

The Exhausting Syringe is much larger than the hypo- 
dermic syringe. It consists of a glass cylinder encased in 
a metal mounting, which is fenestrated so that the fluid 
can be seen as it is drawn into the syringe. There are 
two branches upon which the needles may be fitted. A 
valve is placed at their junction, and connected, by means 
of small bars and joints, with a handle running along the 




Fig. 115.— Dieulafoy's Exhausting Syringe 

side of the cylinder. When the handle is depressed, the 
valve rotates, closing one of the branches ; when the 
pressure is taken off, a spring returns the handle to its 
former position, the valve closing the branch previously 
opened (see Fig. 115). By this means the entrance of air 
into the needle is prevented. 

Two needles accompany the instrument — a large and 
a smaller one ; the former to be used when pus is sus- 
pected, the latter when you expect to find serum. 

The needles are first introduced into the part to be 
examined, and then connected with the syringe, either 
directly or by means of a small rubber tube. 



332 PHYSICAL DIAGNOSIS. 

Dr. Dieulafoy, of Paris, the inventor of this instru- 
ment, says that it is always possible to introduce the 
needle without danger in searching for fluid, no matter 
where it is situated or what its nature, and that he has 
never met with an accident in using it. 

If, after obtaining the fluid, any doubt remains as to 
its character, a drop should be placed on a slide and ex- 
amined under the microscope. The diagnostic value of 
such an instrument is so readily appreciated that it is 
not necessary to enter into the details of its application. 

Ihe X-Bay in Diagnosis. 

Professor Roentgen in 1895 discovered the peculiar ray 
to which his name has been given. At first it seemed to 
promise great assistance in the diagnosis of obscure con- 
ditions. The rays are the cathodal rays of an electric 
current passed through a vacuum tube (Crookes' tube). 
It is probable that such rays, but less powerful ones, 
emanate from the anode. The X-rays have the power 
of passing through solid objects. They are not subject 
to reflection or refraction, and produce fluorescence and 
phosphorescence. Their usefulness is at present greatest 
in surgery, in examining the diseases of the bones and in 
locating foreign bodies. In medical diagnosis they have 
been successful in showing enlargements of the heart, 
pericarditis, aneurisms, and calcareous deposits in the 
blood-vessels. Emphysema of the lungs, tumors, cal- 
careous nodules and cavities in their substance and 
pleuritic effusions can be recognized. 

They have been disappointing in mapping out stones 
in the gall bladder, kidneys, or urinary bladder. To one 



SPECULA. 333 

who has made a special study of the shadows produced 
in examining the body with these rays, they are often of 
great assistance, hut it needs long practice and a trained 
eye to obtain from them much assistance. 

Specula. 

Various specula have been devised for exploring the 
nose, the ear, the vagina, the rectum, and the urethra, 
and, in the hands of those accustomed to their use, are 
of material aid in arriving at a more positive diagnosis 
than could otherwise be obtained. 

The endoscope, an instrument constructed for the pur- 
pose of exploring and making applications to the urethra, 
bladder, and rectum, has a series of dark-lined metallic 
tubes, which are employed as specula, and may be used 
with solar or artificial light. The uses of this instru- 
ment are almost exclusively confined to the domain of 
surgery ; I shall not, therefore, include it in the list of 
mechanical aids to medical diagnosis. 



INDEX. 



Abdomen, auscultation of, 138 

difficulties of physical explora- 
tion of, 131 

inspection of, 135 

mensuration of, 136 

methods of physical examina- 
tion, 135 

palpation of, 136 

percussion of, 137 

topography of, 131 

zones of, 132 
Abdominal aneurism, 169 

wall, chronic abscess of, 156 
Abscess of liver, 148 
Acetic acid, test for, 284 
Acidophile, 213 
Actinomyces in sputum, 257 

in urine, 276 
iEsthesiometer, 329 
Albumin, Heller's test for, 197 

in urine, 197 

significance of, 199 

tests for, 197 
Albuminometer, 198 
Ammonio - magnesium phosphate 

crystals in urine, 266 
Amoebae coli in faeces, 290 

in sputum, 259 
Amphoric cough, 51 

resonance, 26 

respiration, 38 

whisper, 50 

voice, 50 
Anaemia, pernicious, blood in, 232 

simple, blood in, 229 
Aneurism, abdominal, 169 

of the arteria innominata, 125 

of thoracic aorta, 121 
diagnosis of, 124 
physical signs of, 121 
Anthrax, bacillus of, 241 
Aorta, 83 

aneurism of thoracic, 121 
Aortic valves, position of, 82 
Ascaris lumbricoides, 294 



Ascites, 139 
Aspirator, 331 
Asthma, spasmodic, 57 

physical signs of, 57 
Asystolism, 119 
Atelectasis, 64 
Auricular diastole, 84 

systole, 84 
Auscultation, 29 

immediate, 29 

intra- thoracic, 39 

mediate, 29 

of the voice, 47 

rules for performing, 30 
Auscultatory percussion, 27 
Axillary region, 10 



Bacillus of anthrax. 241 

typhoid fever, 241 
Bacteria in the blood, 239 
"Barrel -shaped" chest, 55 
Basophile, 213 

Bile ducts, obstruction of, 149 
Bile, Gmelin's test for, 206 

in urine, 206 

Pettenkofer's test for, 207 

Rosin's test for, 206 
Bladder. 160 
Blood, bacteria in, 239 

changes, significance of, 229 

examination of, 211 

guaiacum test for, 207 

in faeces, 288 

in urine, 207, 270 

in vomit, 276 

plates, 213 

pneumococci in, 239 

red corpuscles. 212 

changes in number. 214 
enumeration of, 215 

staphylococci in, 240 

white corpuscles, 213 
enumeration of. 219 
Bothriocephalic latus. 293 
Breathing, costal, 11 



336 



INDEX. 



Breathing, diaphragmatic, 11 

normal. 11 
Bronchi, dilatation of, 54 
Bronchial casts, 252 

cough, 51 

respiration, 33, 37 

whisper, 50 

abnormal modifications of, 
50 
Bronchiectasis, 54 

physical signs of, 55 
Bronchitis, 53 

capillary. 54 

physical signs of, 54 

differential diagnosis of, 54 

physical signs of, 53 
Bronchophony, 47, 49 

whispering, 50 
Broncho- vesicular respiration, 37 
Butyric acid, test for, 284 



Calcium oxalate in urine, 265 
Cancer of liver, 149 

pulmonary, 63 

diagnosis of, 64 
physical signs in, 63 
Cardiac hypertrophy, physical 

signs of, 115 
Cardiac impulse, 89 

murmurs, 109 
table of, 102 
Cardiometer, 303 
Casts in urine, 271 
Cavernous cough, 51 

respiration, 38 

whisper, 50 
Chest, average circumference of, 17 

regions of, 4 

topography of. 3 

vital capacity of, 18 
Chlorides in urine, 190 
Chlorosis, blood in, 229 
Cholera bacillus, 289 
Chyluria, 264 
Cirrhosis of the liver, 151 
Clavicular region, 4 
" Cog-wheel " respiration, 35 
Comma bacillus, 289 
Congestion, pulmonary, 64 
Cracked-pot resonance, 26 
Crepitant rales, 42 
Curschmann's spirals, 251 
Cyrtometer, 302 
Cystin in urine, 267 
Czenzyenski's fluid, 248 



Dicrotism, 312 

Dilatation of the heart, 116 



Diphtheritic exudates, examination 

of, 260 
Distoma hepaticum, 291 
Double pulse, 312 
Dry rales, 40, 41 
Dulness, pulmonary, 25 
Dynamometer, 328 



Eberth's bacillus, 289 
Echinococcus in sputum, 259 

in urine, 276 
Egophony, 49 
Ehrlich's triacid stain, 225 
Elastic tissue in sputum, 252 
Emphysema, pulmonary, 55 
diagnosis of, 57 
physical signs of, 55 
Empyema, 70 

pulsating, 125 
Endocardial murmurs, 99 
Endoscope, 333 
Eosinophils 214 
Epigastric pulsation, 125 

region, 134 

zone, 132 
Epithelium in faeces, 288 

in urine, 270 

in vomit, 277 
Exhausting syringe, 331 
Expiration, prolonged, 36 



Faecal accumulations, 152, 157 

Faeces, 288 

amoebae coli in, 290 
animal parasites in, 290 
ascaris lumbricoides in, 294 
blood in. 288 

bothriocephalus latus in, 293 
cholera bacillus in, 289 
distoma hepaticum in, 291 
epithelium in, 288 
micro-organisms in, 289 
oxyuris vermicularis in, 294 
tenia mediocanellata in, 292 
tenia solium in, 291 
tubercle bacilli in, 290 
typhoid bacillus in, 289 

Fat in urine, 264 

Fatty heart, 119 
liver, 147 

Fehling's test, 201 

Fermentation saccharometer, 204 

Fibroid heart, 119 

Filaria Demarquaii, 249 
diurna, 249 
nocturna, 249 



INDEX, 



Filaria perstans, 249 

sanguinis hominis, 248 
in urine, 276 
Flatness, pulmonary, 25 
Fcetal heart sound, 168 
Fremissement cataire, 91 
Fremitus, friction, 16 

rhonchial, 16 

sonorous, 16 

vocal, 10 
Friction fremitus, 16 

sounds, pericardial. 97 
pleuritic, 40, 45 
Funic souffle, 163 



Gangrene, pulmonary, 62 
Gastric contents, chemical analysis 
of, 278 
significance of examination, 286 
Gmelin's test, 206 
Gonococci, 275 
Gower's solution, 216 
Gunzberg's test, 280 
Gurgles, 43 



Hamiatoscope, 228 

Htemometer, 227 

Heart, abnormal sounds of, 97 

auscultation of, 92 

dilatation of, 116 

duration of phases of contrac- 
tion, 86 

fatty, 119 

fibroid, 119 

foetal sound, 163 

hypertrophy of. 115 

inspection of, 89 

murmurs, 97 

palpation of. 90 

percussion of, 91 

physical examination of, 89 et 
seg. 

physiological action of, 83 

relative position of valves, 82 

sounds of. 93 

modifications of normal, 94 
reduplication of, 96 

surface measurements of, 82 

topography of, 81 
Heller's test, 197 
Hemorrhage, pulmonary, 62 
Hepatitis, acute, 149 
Hydatids of liver, 150 
Hydrochloric acid, tests for free, 

280 
Hydro-pueumothorax, 73 



Hydro - pneumothorax, physical 

signs of, 73 
Hypertrophy, cardiac, physical 

signs of, 115 
Hypochondriac regions, 134 
Hypogastric region, 134 



Iliac regions, 135 
Infra-axillary region, 10 
Infra-clavicular region, 5 
luframammary region, 6 
Infra-scapular region, 9 
Inspection, 11 

in pleurisy, 12 

in pulmonary emphysema, 1! 
Interrupted respiration, 35 
Inter-scapular region, 9 
Intestines, physical signs of, 142 



Jugular pulsation, 127 

K 

Kelling's test, 283 
Kidney, movable, 160 
Kidneys, location of, 158 

physical examination of, 159 



Lactic acid, Kelling's test for, 283 
Laryngeal mirror, 304 

respiration, 33 
Laryngophony, 47 
Laryngoscope, 304 
Larynx, abnormal appearances, S07 

method of examining, 305 

normal appearance, 306 
Leucin in urine, 267 
Leucocytes, 213 

enumeration of, 219 
Leucocytosis, 221 
Leukaemia, blood in. 222 
Lipuria, 264 
Liver, abscess of, 148 

cancer of, 149 

cirrhosis of, 151 

congestion of, 149 

diagnosis of diseases, 152 
table of. 153 

displacements of, t">4 

fatty, 147 

hydatids of. 150 

normal boundaries, 144 

variations in size, 147 



338 



INDEX. 



Liver, waxy, 147 
Lobar pneumonia, 58 
Lobular pneumonia, 60 
Loeffler's methylene blue, 262 
Lower sternal region, 7 
Lumbar regions, 134 
Lymphaemia, 223 
Lymphocytes, 213 

M 

Macrocytes, 226 
Mammary region, 6 
Mast cells, 214 
Megaloblast, 227 
Mensuration, 16 

in disease, 17 
Mesenteric enlargements, 172 
Metallic tinkling, 51 
Microcytes, 225 
Microcythsernia, 225 
Micro-organisms in urine, 274 
Microscope, 326 

method of using, 327 
Miliary tuberculosis, acute, 74 
Mitral valve, position of, 82 
Moist rales, 40, 42 
Movable kidney, 160 
Mucous click, 44 

rales, 43 
Mucus in urine, 268 
Murexide test, 185 
Murmur, aortic obstructive, 109 
regurgitant 109 

mitral regurgitant 110 

rhythm of, 99 
Murmurs, anaemic and functional, 
108 

area and rhythm, 106 
aortic, 106 
mitral, 104 
pulmonic, 105 
tricuspid, 105 

cardiac, 109 

table of, 102 

endocardial, 99 

seat of, 103 

subclavian, 126 

valvular, 99 

venous, 108, 127 

ventricular, 111 
Myelocytes, 214 
Myelocythaemia, 222 



N 



Nasal speculum, 308 
Neutrophil^ 213 



(Edema, pulmonary, 61 
diagnosis of, 61 
physical signs of, 61 
Oligocythaemia, 215 
Omental tumors, 171 
Omentum, cancer of, 156 

tuberculosis of, 156 
Ophthalmoscope, 315 
Optic disc, appearances of, 317, 318 

atrophy of, 320 
Optic neuritis, 319 
Ovaries, 165 

diagnosis of tumors, 167 

physical examination of tu- 
mors, 166 
Oxyuris vermicularis, 294 



Palpation, 14 
Pectoriloquy, 49 

whispering, 50 
Percussion, 19 

auscultatory, 27 

immediate, 19 

in disease, 24 

in health, 22 

mediate, 19 

rules for performing, 21 

sound, duration of, 20 
intensity of, 20 
pitch of, 20 
quality of, 20 
Pericardial friction sounds, 97 

sac, 83 
Pericarditis, physical signs of, 113 
Peritonitis, acute, 139 

chronic, 139 
Pettenkofer's test, 207 
Phenyl-hydrasin test for sugar, 202 
Phonendoscope, 301 
Phosphates in urine, 187 
Phthisis, chronic, 75 
Physical diagnosis, definition of, 3 

methods of, 3 
Plasmodium malarise, 241 

aestivo-autunmal parasite, 245 

crescents, 246 

flagellated bodies, 247 

tertian parasite, 241 
Plehn's solution, 248 
Pleurisy, 66 

acute, 66 

physical signs of, 66 
stages of, 66 et seq 

classification of, 66 

diagnosis of, 70 

subacute, 68 



INDEX. 



33y 



Pleurisy, subacute, physical signs 

of, 69 
Pleurodynia, diagnosis from pleur- 
isy, 71 
Pleximeter, 21 
Pneumococci in sputum, 257 
Pneumo-hydrothorax, succussion 

in. 28 
Pneumonia, acute tubercular, 75 
lobar, 58 

gray hepatization in, 59 
physical signs of, 58 
red hepatization in, 59 
lobular, 60 

diagnosis of, 61 
physical signs in, 60 
Pneumothorax, 72 

physical signs of, 72 
Poikilocytes, 226 
Poikilocytosis, 226 
Pubic region, 134 
Pulmonary artery, 83 
congestion, 64 
tuberculosis, 74 et seq 
valves, position of, 82 
Pulsating empyema, 70, 125 
Pulse curve, 311 
Pulse-rate, normal, 86 
Purdy's test for albumin, 198 

for sugar, 203 
Purring thrill, 91 
Pus cells in vomit, 277 
in freces, 288 
in urine, 208, 269 
Pyuria, 208 



Rale redux, 60 
Rales. 40 

classification of, 40 
Ray fungus in sputum, 257 
Relapsing fever, spirillum of, 238 
Resonance, amphoric, 26 

cracked-pot, 26 

exaggerated pulmonary, 25 

normal vocal, 47 

of cough, 51 

tympanitic pulmonary. 25 

vesiculo-tympanitic, 26 
Respiration, absent or suppressed, 35 

amphoric, 38 

bronchial, 33, 37 

broncho-vesicular, 37 

cavernous, 38 

"cog-wheel, " 35 

diminished or feeble, 35 

exaggerated, 34 

in disease, 34 

in health, 31 



Respiration, interrupted, 35 , 

laryngeal, 33 

rude, 37 

table of abnormal, 34 

tracheal, 33 

vesicular, 32 
Respiratory sounds, abnormal, 40 

normal, 31 
Retina, appearances of, 317, 318 
Rhinoscopy, 307 
Rhonchi, 40 
Rhonchial fremitus, 16 
Rosin's test, 206 
Rouleaux, 212 
Round worm, 294 
Rude respiration, 37 



Saccharometer, 204 

Sarcina3 ventriculi in vomit, 277 

Scapular region, 9 

Sepulchral cough, 51 

Serum diagnosis, 232 

Sibilant rales, 41 

Sonorous fremitus, 16 

Sonorous rales, 42 

Sound, elements of, 19 

Spasmodic asthma, 57 

Specula, 333 

Speculum, nasal, 308 

Spermatozoa in urine, 271 

Sphygmograms, 311 

Sphygmograph, 309 

Spirometer, 18 

Spleen, physical signs of, 154 

Sputum, actinomyces in, 257 

alveolar cells in, 251 

amoebse coli in, 259 

cellular elements of, 250 

Curschmann's spirals in, 251 

echinococcus in, 259 

elastic tissue in, 252 

epithelium in, 251 

examination of, 250 

fibrinous coagula in, 252 

liver cells in, 251 

method of staining for tubercle 
bacilli, 254 > 

pneumococci in, 257 

pus cells in, 251 

red blood cells in, 251 

staining solutions for. 253 

tubercle bacilli in. 253 

white blood cells in, 251 
Stothometer, 17, 301 
Stethoscope. 30, 299 
Stomach, cancer of. 142, 156 

distention of, 1 12 

physical signs of. 141 



340 



INDEX. 



Subclavian murmurs, 126 
Subcrepitant rales, 43 
Succussion. 28 
Sugar in urine, 201 

significance of, 206 

tests for, 201 
Sulphates in urine, 193 
Supra-clavicular region, 
Supra-scapular region, 9 
Supra- sternal region, 7 



Taenia mediocanellata, 292 

saginata. 292 

solium, 291 
Temperature, diurnal variation in 

disease, 324 

normal, 322 

range in disease, 323 
in health, 323 
Test- breakfast, Ewald's, 278 
Thermometer, 321 
Thread worm, 294 
Toisson's solution. 216 
Topfer's test, 280 
Tracheal respiration, 38 
Tracheophony, 47 
Tricuspid valve, position of, 82 
Triple phosphate crystals in urine, 

266 
Trocar, 330 
Trommer's test. 201 
Tubercle bacilli, 241 

in fasces, 290 

in sputum, 253 

in urine. 276 

in vomit, 278 

stains for, 253 
Tubercular pneumonia, acute, 75 
Tuberculosis, pulmonary, 74 et seq. 
acute miliary, 74 

chronic pulmonary, 75 
advanced stage, 77 
early stage. 75 
Typhoid bacillus in fasces, 289 

fever and Widal's reaction, 238 
bacillus of, 241 
Tyrosin in urine, 267 



U 



Umbilical region, 134 

zone, 132 
Upper sternal region, 7 
Urates in urine, 186, 263 
Urea in urine, 181 
Ureometer, 181 
Uric acid crystals in urine, 264 

in urine, 185 



Uric acid, murexide test for, 185 
Urine, 175 

abnormal elements in, 197 
actinomyces in, 276 
albumin in, 197 

significance of, 199 
ammonio - magnesium phos- 
phate crystals in, 266 
bile in. 206 
blood in, 207, 270 
calcium carbonate in, 264 

oxalate in, 265 

phosphate crystals in, 267 

phosphate in, 264 
casts in, 271 
chemical characters, 181 
chlorides in, 190 
color of, 178 
cystin in, 267 
deposits in, 181 
echinococcus in. 276 
epithelium in, 270 
fat in, 264 

filaria sanguinis hominis in, 276 
leucin in, 267 
micro-organisms in, 274 
microscopic examination of, 

262 
mucus in, 268 
odor of, 178 
phosphates in, 187 
physical characters, 176 
plan of examination, 175 
pus in. 208, 269 
quantity in twenty-four hours', 

176 
reaction of. 179 
specific gravity of, 179 
spermatozoa in, 271 
sugar in, 201 

significance of, 206 
sulphates in. 192 
triple phosphate crystals in, 266 
tubercle bacilli in, 276 
tyrosin in. 267 
urates in. 186, 263 
urea in, 181 

variations in quantity, 185 
uric acid in, 185 

crystals in, 264 

variations in quantity, 186 
xanthin in, 268 
Uterine bruit, 162 
Uterus, 161 

auscultation of, 161 
tumors of, 165 



Valvular murmurs, 99 



INDEX. 



341 



Veins, 126 

turgescence of, 126 
Venous hum, 108 

murmurs, 108, 127 

pulsations, 127 
Ventricular diastole, 85 

systole, 84 
Vesicular murmur, 32 

respiration, 32 
Vocal fremitus in disease, 15 
normal, 15 

resonance, exaggerated, 49 
normal, 47 

table of variations in, 48 
Vomit, blood in, 276 

coffee-grounds, 277 

epithelium in, 277 

pus cells in, 277 



Vomit, sarcinse ventriculi in. 277 
the, 276 
tubercle bacilli in, 278 



W 



Waxy liver, 147 
Widal's test, 238 



Xanthin in urine, 268 
X-ray in diagnosis, 332 



Ziehl->Teelson solution, 254 



OCT IS 1899 






